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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' `"� '`� � � o <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD MinnesoNa Unique Well No. �p `�� �� � <br /> County Name <br /> Minnesota Statutes,Cha ter f037 or W-series No. <br /> t�enrte�in p ,�ea�e b�a�k�,�o,k�ow�, <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> OrOnO 117 2� 21 ST� � ?+�rT � <br /> GPS LOCATION— decimal degrees(to four decimal places) / <br /> Depth Before Sealing �j� ft. Original Depth fl. <br /> Latitude Longitude <br /> A�UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �[�� /►�/ <br /> L1C .7 n W LUBORING �Measured ❑Estimated Date Measured�p„�` �!`i f <br /> �C?1 J .�lat+� , �i� IJrOT�� Water-Supply Well ❑Monit Well f ( <br /> Show exact location ot well or boring Sketch map of well or b �o ,Env.Bore Hole `� <br /> in section grid with"X:' location,showing prope yb� ❑Other �ft. �elow ❑above land surface <br /> N ' � S� CASINGTYPE(S) <br /> ��: --'---—i--—`-- ---'-- ??�� � �,/ <br /> = j j j j � � � I XSteel ❑Plastic ❑Tile ❑Other <br /> � �� <br /> -- —----- ---- ----- `' WELLHEAD COMPLETION <br /> '- ' - ` t <br /> W ' ' ' ' ET , i d IIH G d I d tOff t <br /> � _ �_ _ �_____;__ __�__ I �,}utsi e: ❑We ouse ❑At ra e nsi e: �asemen se <br /> 'h nniie � ❑Pitless AdaptedUnit ❑Buried ❑Well Pit <br /> ` --:-- r----- :-- 1 <br /> �� � ❑Buried <br /> ' S `\` ❑Well Pit <br /> ❑Other <br /> F—i Miie—� ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter t Depth � Set in over���si_z,,,///e hole? Annular space initially grouted? <br /> Properry owner's mailing ad ess if ditterent ihan well location address indicated above ��n.from�`�" _ t0��,ft. ❑Yes �o ❑Yes ❑No ❑Unknown <br /> 2C16 it�rth Chestnut in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Chasks�, �rnl 5531� <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � <br /> ��'* ^"� � n � <br /> Well owner's mailing address if diHerent ihan property owner's address indicated above Scfeen ffom�L+�to_�[�_ft. Open Hole ffOm to ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> N ��r� .T'` � <br /> Type of Obstructions(Describe) y4 /l� �' / <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If no[known,indicate estimated formation log from nearby well or boring. ��r �u M� <br /> a Type <br /> D �� �Removed [�Not Present ❑Other <br /> = �M,E`T'HOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �yrvo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforalion/Removal � <br /> /� <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) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material�U���//iL from�_ to?r� �ft. yards� bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> UCENSED OR REGISTERED CONTRACTOR CERTIFICATION � <br /> R���I��� 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 /> �?c�n �talola ��jell Drillin�; Co,.Inc. 1f�91 <br /> JUN 0 3 2 p�6 Licensee Business Name License or Registration No. <br /> CITY OF ORONO �- l '�� - I Co -- <br /> i prASentative�gnat Certilied Rep.No. Date <br /> � ; <br /> _ • <br /> " � ���8 2 .` �"`.�.,-.�. ` <br /> LOCAL COPY oe Name of Person Sealing Well or Bor'g <br /> HE-01434-14 ID#53159 ' / 5/13R <br />