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WELL OFt BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H275521 <br /> County Name WELL AND BORING SEALING RECORD MinneSealinsota oaUnique Well No. <br /> Minnesota Statutes,Chapter 103! or W-series No. <br /> Hennepin (leave blank if-known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 33 SW SW SC f F,</� j <br /> � <br /> GPS Latitude degrees__ _ minutes _ seconds Depth Before Sealing /90 <br /> ' ft. Original Depth _ ft. <br /> LOCATION: — <br /> Longitude degrees_-___ minutes seconds <br /> - A IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Ingle Aquifer ❑Multiaquifer rn <br /> WELL/BORING Measured ❑Estimated Date Measured �;,n ,4- <br /> 2760 Watertown Rd, Or+�no SS3S6 � - <br /> [XNater-Supply Well ❑Mont.Well 8 <br /> Show exact location of well or boring Sketch map of well or boring Env.Bore Hole <br /> in section grid with"X." location,showing property ❑ ❑Other ft. )Kelow ❑above land surface <br /> lines,roads,and buildings. <br /> N CASING TYPES) <br /> - --t-- <br /> I ❑SteelPlastic ❑Tile ❑Other <br /> ----- ---- -- -- ----- WELLHEAD COMPLETION <br /> W ET House E <br /> [_]r r 'h Mile Outside: Well <br /> Adapter/Unit At Grade Inside: ❑Basement Offset <br /> tPtleLl❑Buried Well Pit <br /> T . 1F <br /> 1 <br /> F]Well Pit ❑Buried <br /> s ❑Other _ <br /> 1 Mile —( 1 J /) p ❑Other <br /> PRQ,eE_RTY.OWER'SNAME/COMPANY NAME CASING(S) <br /> FMZAM Diam e;* t Depth t Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above In.from 10 Yes o Y@S <br /> �ft t. ❑ Ao ❑ ❑No ❑Unknown <br /> SaA1e as above <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 r <br /> Well owner's mailing address if different than property owner's address indicated above Screen from / & to�ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill *0 Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL I COLOR HARDNESS OR FROM TO Obstructions removed? <br /> FORMATION ❑Yes ❑No Describe <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> Type <br /> ❑Removed FVFlot Present ❑Other__.___ _ <br /> ( METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> [>Jo 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 /> (Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> n r <br /> t <br /> Grouting Material Q to_ 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 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 <br /> is true to the best of my knowledge. <br /> Dai Sto&la Well Drilling Co., Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> erti ed Pepresentative Signa Certified Rep.No. Date <br /> ,I <br /> H 275521 } / y' y`Ij <br /> LOCAL COPY Name of Person Sealing Well or Boring <br /> HE-01434-11 IC#140-0423 .! 2,08R <br />