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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 184731 WELL OR BORING LOCATION Sealing No. H County Name i _ WELL AND BORING SEALING RECORD Minnesota Unique Well No. �ener Lit Minnesota Statutes.Chapter 1031 or W-series No. ,� fL—aank n-t k—,) Township Name Township No. Range No Section No. Fraction ism.-►Ig.) Date Sealed Date Well or Boring Constructed Orono 117 23 7 Num encal Street Address or Fire Number and City of Well or Boring Location ^ 1355 Vine Place, Orono 55364 Depth Before Sealing i/ ft Original Depth ft Show exact location of well or boring Sketch map of well or Dring AQUIFER(S) STATIC WATER LEVEL in section grid with'X' location, showing pr eny Single Aquifer ElMulhagwter lines,roads.and buildi s N WELL/BORING )(Measured ❑ Estimated ( YWater Supply Well ❑Mond.Well ❑ Env.Bore Hole ❑Other ft below ❑ above land surface ( W -T- - -- - -- -- -- E J CASING TYPE(S) , --�- - -- ---- ----- y Steel ❑ Plastic ❑Tile ❑Other Yemile , CASING(S) 1 Diameter Depth Set in oversize hole? Annular space initially grouted? ll S IIt�t mde #L t infrom o /0 ft. ❑ Yes XNo ❑ Yes ❑No ❑ Unknown PROPERTY OWNER'S NAME infrom to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown Property owner's mailing address it different than well location address indicated above. in.from to ft. ❑ Yes ❑ No E) Yes E] No El Unknown sapie as above SCREEWOPENHOLE , k� Screen from f C"' to �O f ft. Open Hole from to ft. OBSTRUCTIONS WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction Well owner's mailing address if different than property owner's address indicated above Type of Obstructions(Describe) - /�/LJ=.+x %''T 4' ✓`/ Obstructions removed? XYes ❑ No Describe PUMP 7Type ..} f iP a)w E GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed E] Not Present El Other FORMATION If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: Jo Annular Space Exists y 4 ❑Annular space grouted with tremie pipe ❑Casing Perforation/Removal in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERIALS) (One bag o�f/cement 94 Ibs.,one bag of bentonite=50 lbs.) Grouting Material N��j �� "tt to N. _ yards — begs 9 from to ft. yards bags from to ff. yards bags from to— h. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes XNo How many? LICENSED OR REGISTERED CONTRACTOR CERTirICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Don S a Warlljllirilljn�4 Co- 27177 Contractor Business Name _ Ucenfse or Registration Pio. 1!�5TdVbd Repro§antetive Signature Ditte LOCAL COPY H .q wName o/Person Sealing WeN or Boring 184731