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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnes�ota Well and Boring I„I � ���� � <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnesoNa Unique Well No. <br /> 5 Minnesota Statutes,Cha ter 103I or W-series No. <br /> ���}�p��M P (Leave blenk�it not knawn) <br /> 114 i� <br /> Township Name Township No. Range No. Section No. Fraction(sm.-»Ig.) Date Sealed Date Well or Boring Constructed <br /> �'�cona l.l? 7.3 ?1 SF ?'�i !+��T d <br /> GPS LOCATION- decimal degrees(to four decimal places) /� � <br /> Depth Before Sealing ��/ ft. Original Depth ft. <br /> Latitude Longitude __ <br /> UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ' Single Aquifer ❑Multiaquifer /��yv <br /> 7/,7fi ��,.� n��C� [>,.� (rC.��� ��'�n� W UBORING Measured ❑Estimated DateMeasured��l� �)/T! <br /> � � Water-Supply Well ❑Monit.Well t � � <br /> Show exact location of well or boring Sketch map of well or boring � <br /> in section grid with"X" location,showing property U Env.Bore Hole ❑Other ft. �below ❑above land surface <br /> N -� lines,roads,and buildings. CASING TYPE(S) <br /> ` --'--- I I I �.,1 <br /> ; �teel ❑Plastic ❑Tile []Other <br /> --'--- --�------�-----+-' �� ELLHEAD COMPLETION <br /> � , � � ;. <br /> �Y� � W <br /> W : ; ; � ET ' : � _ <br /> r <br /> � � _;__ __�__ � ?a� I Outside: ❑Well House ❑At Grade Inside: �Basement Offset � <br /> , , , � <br /> 'h nni�e �—" ❑Pitless AdaptedUnit ❑Buried ❑Well Pit <br /> � � i � 4� � <br /> __'___ __�______�_""_"`_" .. <br /> 1 ❑Buried <br /> ' S ' f! ❑Well Pit <br /> ❑O[her <br /> , i M�ie� ___/` ❑Other <br /> PROPERTY OWNER'gt,�NAME/COMPANY NAME CASING(S) <br /> �t t � �Q''���n Diamete�� r Depth t Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address it diHerent than well location address indicated above �in.from_� to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> f � <br /> Well owner's mailing address if different than property owner's address indicated above Sc�BBn from_�_to__���ft. Open HOIe from to ft. <br /> OBSTRUCTIONS <br /> ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> (�.. �'^' �i <br /> TypeofObstructions(Describe).,,�/V1�/+�� /"1� 9- �f�f <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ❑No Describe <br /> FORMATION <br /> If not known indicate estimated formation log from nearby well or boring. PUMP �^�, <br /> � i TYPe � " t ��'1� <br /> i� /�.i � <br /> ✓ �emoved ❑Not esent ❑Other <br /> T <br /> i <br /> � METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> [�lo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <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 TNtI <br /> GROUTING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite-50 Ibs.) <br /> � <br /> Grouting Material �iG�`i���rom�� to�_�ft. yards�__ bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS �� <br /> HEMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> RECL11/�� 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 /> �UI� o � �016 �'� �to�iola Fl�ll I�rillin;� Co, Inc. Ih�l <br /> Licensee Busine�ss Name License or Registration No. <br /> r <br /> �IT�'OF ORONO `�� . �-' �' � 1 (�a <br /> C 'i �fi p 'sentahve Sign r Certified Re p.No. Date <br /> H � � �*'1 tv � � '.��� w-"a ' ��._.,. �: �, ��I��)V'v. <br /> LOCAL COPY •✓ �..3°�� � Name of Person Sealing Well or Boring f <br /> HE-01434-14 ID#53159 5n3R <br /> � <br /> .� I <br />