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3 BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H o. 4 0 5 8 7 9 <br /> me WELL AND BORING SEALING RECORD MinSeanesota Na Unique Well No. <br /> NEPIN Minnesota Statutes,chapter 103i or W-series No. <br /> (Leave dank it not known) <br /> lame Township No. Range No. Section No. Fraction(sm.-a lg.) Date Sealed Date Well or Boring Constructed <br /> MO 117 23 05 NFINESE ,k11/21/23 <br />\TION—decimal degrees(to four decimal places) <br /> 1 <br /> Depth at Time of Sealing 16 ft. Original Depth ft. <br /> Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Street Address or Fire Number and City of Well or Boring Location IR Single Aquifer ❑Multiaquifer 1`/ZZ/Z� <br /> WELL/BORING Measured Date Measured ❑Estimated <br /> OXFORD ST.,ORONO, MN. 55356 <br /> [,Water-Supply Well ❑Env.Well <br /> t location of well or boring Sketch map of well or boring ,,--77rr'' <br />)rid with"X." location,showing property ❑Temp.Boring ❑Other 8 ft. Ai, ❑above land surface <br /> line,roads,and buildings.N CASING TYPE(S) <br /> rl 1, IDSteel IrPlastic IIITile ❑Other <br /> X WELLHEAD COMPLETION <br /> E �.. f� <br /> r T k. Outside: p Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> h MAll !`i ❑Well Pit ❑Buried ❑Well House <br /> T II T_* 0 4::::) <br /> ❑Well Pit <br /> . 1 <br /> 9 <br /> ❑Buried <br />—1 Mile I <br /> ❑Other <br /> rary borings,provide additional location 1 <br /> ❑Other CASING(S) <br /> t,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially'grouted? <br /> yrOWhIE RreMf/COMPANY NAME 4 in.from 1 to 106 ft. El Yes 0 No ❑Yes ❑No ❑Unknown <br /> ner's mailing address if different than well location address indicated above in.from to (t. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 'in.from to ft. ❑Yes 0 No ❑Yes ❑No ❑Unknown <br /> SCREEN/OPEN HOLE <br /> W-. Screen from 106 to 116 ft. Open Hole from to ft. <br /> JER'S NAME/COMPANY NAME 7 !� <br /> REAL&ESTATE I.1.0 OBSTRUCTIONS <br /> mailing address if different than property owner's address indicated above [!ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> 5 FOX STREET Type of Obstructions(Describe) drop pipe <br /> NO, MN. 55356 <br /> Obstructions removed? M Yes ❑No Describe <br /> PUMP <br /> HARDNESS OR <br /> 3ICAL MATERIAL" COLOR FORMATION FROM TO ❑Not Present (Present,Removed Prior to Sealing ❑Other <br /> in,indicate estimated formation log from nearby well or boring. rsibl* <br /> i Type <br /> ft 1 116 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> AIL Annular Space Exists ❑Annular Space Grouted with Tremie 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 XNo TN# <br /> GROUTING MATERIAL(S) 9 <br /> Grouting Material Neat Cement from 1 to 116ft. yards bags <br /> 9 <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 Z No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> i,SOURCE OF DATA,DIFFICULTIES IN SEALING This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. <br /> DON STODOLA WELL DRILLING CO„ INC. 1691 <br /> Licensee Busin s Na a '' License or Registration No. <br /> 11/22/23 <br /> e edt-representative Signature Certified Rep.No. Date <br /> LOCAL COPY H 4 0 5 8 7 9 Jerry Barr <br /> Name of Person Sealing Well or Boring <br /> 17 ID#53159 ili19R <br />