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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring +� �j <br /> WELL OR BORING LOCATION Sealing No. �H_ 3 <br /> County Name WELL AND BORING SEALING RECORD Minnesota unique well No. L� — <br /> 96 <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave Clerk M not krawn) <br /> Township Name Township No. Range No Section No. Fraction ism -i Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 11.3 23 31 31-0,005 /8 04:f7-- 61 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location { <br /> 385 Turnham Rd, Orono 55359 Depth Before Sealing ft Original Depth <br /> Show exact location of well or boring Sketch map of well of boring A_O)JIFER(S) STATIC WATER LEVEL <br /> in section grid with"X'. location, showing p ^Single Aquifer ❑ Multiaqulfer <br /> lines,roads,and buil ngs <br /> N WE/LUBORING Measured [I Estimated <br /> +� /Water Supply WeII ❑Monit.Well h �/ <br /> ❑ Env Bore Hole ❑Other ft. ij�below ❑ above land surface <br /> W -- - - -- 'i'" '-�-- E CASING TYPE(S) <br /> - - -- -i-- --�-- �\ Steel ❑ Plastic ❑Tile ❑ Other <br /> }Amite <br /> CASING(S) <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> S Z .> <br /> �L -1 mile in.from 4 to—5K�— If. ❑ Yes No ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> Charles Phelps <br /> Property owner's mailing address if different than well location address indicated above. infrom to If. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> t0 <br /> / <br /> 6 <br /> Screen from_ �to_1_ !. ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑Check Vallvve�(s)) ❑ Debris /❑ Fill ❑ No Obstruction /}7- /�(� <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) Lam+/ 1 /'-tJ� e 1466/w6"-T <br /> Obstructions removed? k.s ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ❑ Removed X, <br /> Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> driftf No Annular Space Exists <br /> U r i.`t ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> //� 0.-�-'-' <br /> Grouting Material �!W7- ���%"'" m � to 11..�e fl. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to_ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes XNo 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 is <br /> true to the best of my knowledge. <br /> Fon 8todola Well Drillin, Co, Inc. 27172 <br /> ContractoZB�usiness me License or Registration l'ro. <br /> r - 10-18-0 <br /> ofho resentaffve Signature Date <br /> Jim Antonson <br /> H /1/1 Name of Person Sealing Well or Boring <br /> LOCAL COPSE BMJ!L1 <br />