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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br />County Name WELL'AND BORING SEALING RECORD nnl <br />ng No. <br />Mieso a Ulruque Well No. <br />Minnesota Statutes, chapter 1037 orreW seriees,�N°I <br />TT �iM <br />H 389.624 <br />Township Name <br />Township No. <br />Range No. <br />Section No. <br />Fraction (sm. -+ Ig.) <br />Date Sealed <br />Date Well or Boring Constructed <br />HMS fO <br />j1'_7_- <br />23 <br />04 <br />I 7? W,4 Nig <br />4/2 2 <br />GPS LOCATION - decimal degrees (to four decimal places) <br />Latitude Longitude <br />Depth at Time of Sealing 122 ft. <br />Original Depth ft, <br />AQUIFER(S) <br />Single Aquifer ❑ Mutilaquffer <br />STATIC WATER LEVEL <br />Measured Date Measured 4123121 [1 Estimated <br />73 ft. DC below ❑ above land surface <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />5 Watertown Road OronoWater-Supply <br />WELL/BORING <br />Well ❑ Env. Well <br />❑ Temp. Boring ❑ Other <br />Show exact location of well or boring Sketch map of well or boring <br />in section grid with "X" location, showing property <br />N �r� rt'lines, roads, and bpildings. <br />CASINGTYPE(S) <br />jjj}}}y <br />[X Steel ❑ Plastic ❑ Tile ❑ Other <br />------ i <br />1 <br />W 1 I E T <br />i s - ---1-- I <br />'b Mlle <br />--�--- --T-- --%-- ------ <br />,1 <br />s t y <br />—t Mlles <br />WELLHEAD COMPLETION <br />Outside: Pitiless Adapter/Unit El At Grade Inside: ❑Basement Offset <br />` <br />❑ Well Pit ❑ Buried ❑ Well House <br />El Well Pit ' <br />❑ Other <br />❑Buried <br />❑ Other <br />For temporary borings, provide additional location <br />CASING(S) <br />information, a site sketch, and geology on a separate page. <br />Diameter Depth Set in oversize hole? Annular spade initially grouted? <br />4 in. from 1 to 106 ft. ❑ Yes ❑ No ❑ Yes ❑ No Unknown <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Retfi Trautman <br />Property owner's mailing address if different than well location address indicated above <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />SCREEWOPEN HOLE <br />Screen from 108 to ft. Open Hole from to ft. <br />WELL OWNER'S NAMEICOMPANY NAME <br />OBSTRUCTIONS <br />[ItRodstDrop Pipe ❑Check Valve(s) El Debris El Fill ❑ No Obstruction <br />i <br />Well owner's mailing address if different than property owner's address indicated above <br />Type of Obstructions (Describe) drop pie— <br />Obstructions removed? N Yes ❑ No Describe <br />PUMP <br />El Not Present tX Present, Removed Prior to Sealing ❑ Other <br />Type suhMPrSihl0 <br />GEOLOGICAL MATERIAL COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TO <br />If not known, indicate estimat ormation log from nearby well or boring. <br />T)ri ft <br />1 <br />112METHOD <br />USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />[XNo Annular Space Exists ❑ Annular Space Grouted with Tremfe Pipe ❑ Casing Perforation/Removal <br />Casing Diameter <br />In. from to ft. ❑ Perforated ❑ Removed <br />in. from to ft. ❑ Perforated ❑ Removed <br />Type of Perforator <br />VARIANCE <br />Was a variance granted from the MDH for this well? ❑ Yes ® No TN# <br />GROUTING MATERIAL(S) <br />Grouting Material MORt CA-MA�[tt from 1 to 112 ft. yards � bags <br />from to ft. yards bags <br />from to ft. yards bags <br />OTHER WELLS AND BORINGS <br />Other unsealed and unused well or boring on property? ❑ Yes t,4 No How many? <br />LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br />This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The information contained in this report <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />is true to the best of my knowledge. <br />Ian Stodola Well Drillin- Co Inc 1691 <br />Licensee Business Name License or Registration No. <br />4123/21 <br />r se tafive Si iisf re Certified Rep. No. Date <br />CV rarC <br />LOCAL COPY <br />H �r 8 16 4 <br />Name o/ arson Sealing Well or Bating <br />HE -01434-17 ID# 53159 11/79A <br />