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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL OR BORING LOCATION Sealing No. H 164455 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. — <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Rene p i rt....tr.kxnakr.r.1 <br /> Township Name Township No. Range No. Section No. Fracctionn(Sm...-+.wIg.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 07 �1''4OO 3 L 60 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location f at.,0 it <br /> 1200 <br /> Wildhurat Hyl, Orono Depth Before Sealing 34.3 ft. Original Depth 3a n <br /> Show exact location of well or boring ;55ce Sketchkemapof well or boringAO IFER S STATIC WATER LEVEL <br /> in section grid with"X". � location, showing property Single(Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. ..S.��Y""""___ <br /> N WELL/BORING Measured ❑ Estimated <br /> Water Supply Well ❑Monit.Well <br /> ❑ Env.Bore Hole ❑Other <br /> 90 f ft. below ❑above land surface <br /> W--�-'-'-�'---� E CASING TYPE(S) <br /> ---r- i----; 1 NA Steel ❑ Plastic ❑Tile ❑Other <br /> 1 I I I j`1mi <br /> \\ CASING(S) <br /> I • 0 Diameter Depth rf Set in oversize hole? Annular space initially grouted? <br /> LLLL���� S , `' <br /> yam—r mile 9 in.from 0 _,3 ,,fivto ft. ❑ Yes I=No ❑ Yes ❑ No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes 0 No ❑ Unknown <br /> Mike Holleabstat 495-9897 <br /> Property owner's mailing address if different than well location address indicated a ove. in.from to ft. ❑ Yes ❑No ❑ Yes, ❑No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> Screen from to ft. Open Hole from g�j' rto 365 h. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME <br /> 0 Rods/Drop Pipe ❑Check Valve(s) 0 Debris 0 Fill No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) <br /> Obstructions removed? 0 Yes 0 No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO 0 Removed 'X Not Present CIOther <br /> FORMATION <br /> 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: <br /> do Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> `J r -UV}',..,--..b1.... . 35..10,5,0 Casing Perforation/Removal <br /> in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> ar <br /> 45/#1 <br /> Grouting MaterialT Lf _ to ft. 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 y� <br /> Other unsealed and unused well or boring on property? 0 Yes IXJI��1\No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> L,-,�+4' E' 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 /> MAR 3 0 2404 Don gtadola Weil Drilling Co., Ise. 27172 <br /> Contractor Busine Name ' License or Registration No. <br /> Glc ur iJ11C3iV0 /riS/ 4 o <br /> u -• •epresentative '•-,ture Date <br /> j <br /> LOCAL COPY H 164455 Name of Person Sealing W Boring <br />