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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 355 <br /> 217 Q <br /> Q <br /> WELL AND BORING SEALING RECORD Sealing No. <br /> County Name Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W series No. <br /> Herme in <br /> Township Name Township No. Range No. Section No. Fraction(sm. Ig.) Date Sealed Date Well or Boring Constructed <br /> Ocono <br /> 11-- 23 03 1-311411 mt <br /> GPS LOCATION—decimal degrees(to four decimal places) j } C� <br /> Depth at Time of Sealing /+ • ft. Original Depth ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer /�, / <br /> 500 Willow Dr S Grano, WELL/BORING Measured Date Measured ❑ stimated <br /> Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or b 'ri <br /> in section grid with"X:' ocation,showing grope ❑Env.Bore Hole ❑Other _ a y ft. below ❑above land surface <br /> N line�rds,and buildm s CASINGTYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> ---5-----t-- WELLHEAD COMPLETION RECEIVED <br /> W EOutside: 'Iess Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> �A <br /> 'h Mile ❑Well Pit ❑Buried El Well House JAN `I 6 2018 <br /> T <br /> { ❑Other <br /> Ll Well Pit <br /> �1 Miley f ❑Buried❑Other CITY OF ORONO <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above 41 <br /> in.from to-/-2.5 ft. ❑Yes X No ❑Yes ❑No ❑Unknown <br /> 700 East Lake St in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> x`213 <br /> Wayzata, ININ. 55391 in.from to ft. ❑Yes [:1 No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> i <br /> Well owner's mailing address if different than property owner's address indicated above Screen from /- �.+ toja2 q _ft. Open Hole tram to ft. <br /> OBSTRUCTIONS ,! <br /> ❑Rods/Drop Pipe ❑Check Valve(s) El Debris E]Fill p[I No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL I COLOR HARDNESS OR FROM TO Obstructions removed? L1 Yes El No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> Not Present ❑Present,Removed Prior to Sealing E]Other <br /> U <br /> Type <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> Nc Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> Casing Diameter <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 wee f? Q Yes VNo TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �] <br /> Grouting Material/ e-� e-12- '-,-A from to,� 9 ft. yards t 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 YrNo 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 /> DIM STODM A WML TWILLI'', CO., IM. 1691 <br /> Licensee Business Name License or Registration No. <br /> -Z;� <br /> CvVhfdRbfi?esjntativ&S6nftne Certified Rep.No. Date <br /> LOCAL COPY H 352178 <br /> Name of Person Sealing Well or Boring <br /> HE-01434-15 ID#53159 _, visa <br />