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11/79rt <br />HE -01434-17 IDN 63159 ' Aj , <br />MINNESOTA DEPARTMENT OF HEALTH 1411Dn8Sofa Well and Boring <br />WELL AND BORING SEALING RECORD 'Sealing <br />nesot, No. <br />well No. <br />Minnesota Statutes, chapter 1037 •• or W-series No. <br />i� (Leave Wank Hoot known) <br />H Q /� <br />��11 "t <br />WELL BORING LocaTloN <br />Na <br />County Name <br />{{ �gyyyy <br />3�,n.i7.•Fi <br />Township Name <br />Orono <br />Township No. ` <br />1173 <br />Range No. <br />Section No. <br />J7 <br />Fraction (sm. -'Ig.) <br />AW M & <br />Dafe Sealed <br />Date Well or Boring Constructed <br />GPS LOCATION - decimal degrees (to four decimal places)-- <br />Latitude Longitude <br />Depth at Time of Sealing ft. <br />3 <br />Original Depth—- ft. <br />Numerical Street Addressor Fire Number and City of Well or Boring Location <br />1366 Rest Point & Oroao AM <br />AQUIFER(S) <br />Single Aquifer ❑ Mulltaquifer1 <br />STATIC WATER LEVEL <br />A <br />Date Measured "rtat �T []Estimated <br />% ft. below ❑ above land surface <br />W€LL/BORINGMeasured <br />Water-Supply Well❑Env. Weil - <br />Tem Boring Other <br />p g ❑ <br />Show exact location of well or boring Sketch map'of well or boring <br />in section grid with "X." t5 }},, location, showing property <br />CASINGTYPE(S) <br />N+a lines, roads, and buildings. <br />Steel ❑ Plastic ❑ Tile ❑ Other <br />-*+4 <br />WELLHEAD COMPLETION <br />W E <br />TOutside: <br />h Mlle `� <br />, <br />ElPitless Adapter/tJnit • El Grade Inside: [ Basement Offset <br />E] Pi Pit ❑Buried ❑ Well House <br />El Well Pit <br />s <br />❑ Other <br />❑ Burled _ .. <br />f1 rutile— --{ <br />❑Other <br />For temporary borings, provide additional loc on <br />information, a site sketch, and geology on a s parate page. <br />CASING(S) <br />Dia ter ` Depth Set in oversize hole? Annular space initially grouted? <br />in.,from to _ ft. ❑ Yes No ❑ Yes ❑ No . ❑ Unknown <br />PROPER Y OWNER'S NA EICOMPANY AME <br />in. from to it. ElYes ElNo El Yes [-INo. : ❑ Unknown' <br />Property owner's mailing address if different th n el` cation address indicated above <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />SCREEWOPEN HOLE <br />Screen from_ toff. Open Hole from to ft. <br />WELL OWNER'S NAMEJCOMPANY NAME <br />OBSTRUCTIONS <br />V Rods/Drop Pipe ElCheck Valve(s) ❑ Debris . ❑ Fill El No Obstruction <br />YT' <br />Well owner's mailing address if different than property owner's address indicated above <br />t <br />Type of Obstructions (Describe) <br />Obstructions removed 15(Yes ❑ No Describe <br />PUMP s <br />❑Not Present .Present, Reino'ved Prior to Sealing El Other <br />Type Lz <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 />GEOLOGICAL MATERIAL <br />COLOR <br />HAflDNESS OR <br />FORMATION <br />FROM <br />TO <br />if nol nown, indicate estimated formation log from nearby well or boring. <br />asing 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 well? ❑ Yes o TNN <br />GROUTING MATERIAL(S) <br />GroutingMaterial-AJ-& tfrdkn to ft' Yards bags <br />from to f(. yards bags <br />from to ft_ yards bags <br />OTHER WELLS AND BORINGS <br />Other unsealed and unused well or boring on property? ❑ Yes No 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 />REMARKS, SOURCE OF'DATA, DIFFICULTIES IN SEALING <br />DOX STOPOLA. WELL RRIULING CO.* INC, 16' 1_ <br />Licensee Business Name License or Registration No. <br />5567e <br />rtirr Represen ativ Si alure Certified Rep. No. Date' <br />& tn�.' <br />LOCAL COPY <br />H 381412Name <br />of Person Sealin Well or Borin <br />9 9 '• <br />11/79rt <br />HE -01434-17 IDN 63159 ' Aj , <br />