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WE��OR BORING LOCATION MINNESOTA DEPARTMENT GF HEALTH Minnesota Well and Boring H 21515 6 <br /> County Name <br /> WELL AND BORING SEALING RECORD M nnfesoNa Unique Well No. <br /> or W-series No. <br /> Henne�i n Minnesota Statutes,Chapter 1031 �QaVe��a�k��o�k��w�; <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 118N 23 31 � � _C Q� <br /> GPS Latitude degrees minutes seconds / , <br /> LOCATION: Depth Before Sealing ft. Original Depth ft. <br /> Longitude degrees minutes seconds FER(S) STATIC WATER LEVEL <br /> Numerical S[reet Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> WELUBORING �easured ❑ Estimated <br /> 472 �`�� •` � <br /> ��(Water Supply Well ❑Monit.Well / �/1 <br /> Show exact location of well or boring �Sketch map of well or boring /� //j.� <br /> in section grid with"X" �����location,showing property ❑ Env.Bore Hole ❑Other J�ft. �below ❑above land surface <br /> N lines,roads,and bu ing � CASING TYPE(S) <br /> Steel ❑ Plastic ❑Tile ❑Other <br /> W -- - - -- - -- — — E WELLHEAD COMP�ETION <br /> � � � � � Outside: ❑Well House Inside: ❑Basement Offset �- <br /> ---- -�-- -;— --i— �/ <br /> � <br /> � � � y�m��e '� : <br /> � i t�;��� I Z Pitless AdaptedUnit ❑Well Pit ` <br /> --- -i-- -�— --�-- <br /> T` <br /> ❑Well Pit ❑ Buried <br /> S <br /> �{,��'"^° �}�' � ❑Buried <br /> I � `=i...;'.;._�... ��•,.'� <br /> PROPERTY OWNER'S NAME/COMPANY NAME . CASING(S) <br /> � Diamet r/� � Depth �1 j Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing a dress i i erent well location address indicated above /� <br /> � in.ffom to��it. �Yes [�Jo ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ff0i71 t0 ft. ❑Yes ❑ No ❑Yes ❑ No ❑ Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE f f i <br /> Well owner's mailing address if diflerent than property owner's address indicated above Screen from�_t0—_1�ft. Open Hole from f0 ft. <br /> �BSTRUCTIONS <br /> Rods/Drop Pipe ❑ Check V�ve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe�l"��-�`•- / ��r-- ¢ /'C�/�/� <br /> GEOLOGICAI MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? eS ❑ NO Descfibe � <br /> FORMATION <br /> PUMP (//��'� �1 <br /> If not known,indicate estimated formation log from nearby well or boring TYp i-..,n �,`/y� f 1 <br /> ....,�,��„S (J i► �'./ <br /> ,_., *.._.�' � !y `' <br /> �emoved ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> p( No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> /� <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=/94q Ibs.,one�b/ay of bgntonite=50 Ibs.) <br /> Grouting Material /��-'7� ���u r� `�" to�`+�ft, yards � bags <br /> from to ft. yards bags <br /> from to fl. 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 No How many7 <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 is <br /> Vue to the best of my knowledge. <br /> DON STO OLA WELL DRILLIN� eQ. , IATC. 27272 <br /> Contracror Busi s ame , - ' License or Registration No. .-' <br /> ` � �� � � � <br /> o d epresen a e Signat��e Date <br /> „�,� �. ',,�,�° �.��SV.�� Y <br /> LOCAL COPY H Name of Person Sealing Well or Boring /? <br />