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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota <br /> toNWell and Boring H 3 4 6 8 5 3 <br /> SealingCounty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 oe W s eties No. <br /> Hennepin <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 10 NT S NV 6.-//2/17 <br /> GPS LOCATION-decimal degrees(to fourdecimal places) , e <br /> Depth Before Sealing '9 ft. Original Depth_ __ft. <br /> Latitude Longitude <br /> AQUIFERS) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 71099 Willow Dr S, Orono 55391 BORING X Measured ❑Estimated Date Measured-574/774- .•)Ar <br /> ,Water-Supply Well ❑Monit.Well / <br /> Show exact location of well or boring Sketch map of well or boring <br /> in land surface <br /> in section grid with"X:' • location,showing property ❑Env.Bore Hole ❑Other ft. below <br /> N f J + Iiad <br /> A A nes,roads buiidl e� CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> -----•- T WELLHEAD COMPLETION <br /> W <br /> ---1-----1 <br /> _____._ E I ' <br /> Outside: ❑Well House ❑At Grade Inside: y�i,Basement Offset <br /> 'h Mller , i _ ❑Pitless Adapter/Unit ❑Buried LJ Well Pit <br /> r 1 <br /> ❑Buried <br /> s ❑Well Pit <br /> ❑Other <br /> I 1 Mile---I ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Nate Downing D aa/p 5 // , Depth t Set in oversizeiz. o hole? Annular space initially grouted? <br /> Property owners mailing address if different than well location address Indicated above • f2 in.from 8 to 9( ft. 0 Yes ITN ❑Yes ❑No ❑Unknown <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 <br /> r <br /> Well owners mailing address if different than property owner's address indicated above Screen from_ H9)OLE <br /> �� ' ft. Open Hole from to ft. <br /> OBSTRUCTIONS ,,��,,II <br /> ❑Rods/Drop Pipe ❑Check Valve(s) Ill Debris ❑Fill I�No Obstruction <br /> Type of Obstructions(Describe) �` <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If notknown,indicate estimated formation log from nearby well or boring. <br /> Type <br /> aA-I6 j J 9V ❑Removed Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No 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 /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes XNo TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> r <br /> Grouting MateriayiAleiTLiFinF/-4 from to 9(1 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 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 <br /> is true to the best of my knowledge. <br /> nnn SI ty ola 74311 nrilling Co, . Inc_ 1591 <br /> Licensee Business Name License or Registration No. <br /> e died prase ativl� a Si. :turf.' <br /> r Certified Rep.No. Date <br /> " 34635351"-IVv. `d <br /> LOCAL COPY Name of Person Sealing Well or Boring ! <br /> HE-01434-14 ID#53159 f, 5/13R <br />