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WELL OR BORING LOCATiON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring � —� <br /> WELL AND BORING SEALING RECORD Sealing No I H �,�,�,� ,� � �j' <br /> ` Couny Name Minneso!a Unique No. <br /> Ht'{1Fl�ci'�lYi Mmnesota Statutes,Chapter 1031 or W-series No. � <br /> (Leave bla�k if nol known) <br /> � Township Name Township No. Range No Section No. Frachon�sm.-s Ig.) Date Sealed Date Well or Boring Constructetl <br /> � Orono 117 `l3 7 ,, ; 6/29/99 <br /> Numencal Street Address or Fire Number and Ciry of Well or Bonng Location i l <br /> 1405 R�ast Poi�t Roflsi Orono <br /> Depth Betore Sealing j Z N_ Original Depth j� n� <br /> Show exact locanon of�•ell or boring } Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL <br /> in section grid wdh"X'. A � � locafion, showmg property �Smgle AyuAer ❑ Multiaquifer <br /> ,� � lines,roads,and buildin s. <br /> N U WELUBORING � Measured ❑ Eshmated <br /> �]Water Supply Well ❑Monit.Well v <br /> ❑ Env.Bore Hole ❑Other _ drj tt. ❑below ❑ above land suAace <br /> W --�- -�-- - -- --�-- E CASING TYPE(S) <br /> � � � � <br /> . —�- -r- -i-- --�-- � � �]Steel ❑ Plastic ❑Tile � Other <br /> � , � � �mrle V <br /> ' ' ' ' I �` CASING <br /> —�- -i-- -i-- --�-- <br /> � Diameter Depth Set in oversize hole? qnnualar space indially grouted7 <br /> S � � fl ❑ � <br /> L _ �m;�� �_ in Irom to Yes No ❑ Yes ❑No ❑ Unknown <br /> r� <br /> PROPERTV OWNER'S NAME in.trom to fl. ❑ Ves ❑No ❑ Yes ❑No ❑ Unknown <br /> Property owner's mailing address B OiHerent than well loca6on adtlress indicated above. in.from to tt. ❑ �es ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> Screen from � to j L ft. Open Hole from to R. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Vatve(s) ❑ Debris ❑ Fill [�Mlo Obstruction <br /> � Well owners maNirp address A diHarent Man properry owner's address indicated above. Type of ObstruCtiOns(DesCribe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> (iEOlO(i1CAL MATERIAL COLOH HARDNESS OF FROM TO � Removed (�Not Present ❑ Other <br /> FORMATION <br /> N rat krawn,indicete estimeted formatbn lop from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � No Annular Space Exists <br /> dr i f t � 12 ❑ Annular space grouted with tremie pipe <br /> � ❑ Casing Perforation/Removal <br /> in.trom to ft. ❑ Pertorated ❑ Removed <br /> in.from to it. ❑ PeAorated ❑ Remrned <br /> Type ot peAorator <br /> ❑ otner <br /> GROUTING MATERIAL(S) <br /> GroutingMaterial ��rt3'��ld from �'l ro v fl. yards � begs <br /> from to R. yards bags <br /> from to ft. yerds begs <br /> from to-- ft. ya�ds begs <br /> : REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Olher unsealed and unused well or boring on property? ❑Yes �rvo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The infortnation contained in this repoA ia <br /> true to the best of my knowledge. <br /> R�5 we33 Drilliny 1���� <br /> Contractor Business Name License w Registra' fvo. <br /> ,:1�� ==�`-,-�/' '' �� �� � <br /> AuMorized Representative Signefure Dat <br /> James i.�a <br /> Name ol Person Sealing Well a Boring � <br /> LOCALCOPY H <br /> HE-01434-04 8/98 R <br />