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wELL oR BORING LOCAnON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnfesoNa Unique Well No. <br /> ����i� Minnesota Statutes,Chapter 1031 or W-series No. <br /> ��.�dmw n na an�m> <br /> Township Name Township No. Range No. Section No. Frac(ion(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 � 12 �,. �,. Z� � <br /> . - <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Deptli Before Sealing ��� ft. Original Depth ft. <br /> Longitude degrees minutes seconds pUIFER(S) STATIC WATEH LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Locadon ingle Aqu'rfer ❑MulUaqu'rfer <br /> 92rt �� D� S ^rO� WELUBORING �Measured ❑EsUmated <br /> d� n �� Water Supply Well ❑Monit.Well � <br /> Show exact location of well or boring Sketch map of well or boring /_ <br /> in section grid with"X" location,showing property ❑Env.Bore Hole �Other �(,,;�ft. �bebw ❑above IarW surface <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> , � �- � - - � <br /> � ��„' � �Steel ❑Plastic ❑Tile ❑Other <br /> -�C, �, <br /> W --�- -�-- -;-- --;- E �1 � WELLHEAD COMPLETION <br /> � .� i � Outside: ❑Well House Inside: ❑Basement Offset <br /> --i-- -;-- -;-- --i-- - - - <br /> /��� �itless Adapter/Unit ❑Well Pit <br /> --�- -�-- -�-- --1- � � <br /> ` � �� ❑Well Pit ❑Buried <br /> :�, <br /> S ./ �7 <br /> �--�^"'"-�. ' ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diamettt���r� � /Depth R Set in oversize hole? Mnular space initialty grouted? <br /> P er s i mg a dress � rent an we ion a ress indicated above Lf ���.,/ <br /> � in.from� to�:LL ft. ❑Yes �No ❑Yes ❑No ❑Unknawn <br /> /� <br /> 7�] ��Y7��� Bi� in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> St Iauis �xrk 5542b <br /> In.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE , r <br /> Well owner's mailing address if difterent Ma p irWicated above Sc�een ffom�to�ft. Open HOI@ ffOm t0 ft. <br /> OBSTRUCTIONS <br /> NO V 0 3 2006 �Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> CITY i°� Type of Obstructions(Describe) ���J�,� ���'� �' ��m� � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 2S ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated formation log irom nearby well or boring PUMP <br /> i� _ TYPe v''�,� C 1 i`� <br /> "� r''�' Removed ❑ Not Prese t ❑Other <br /> ' r r <br /> f 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 /> r <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bmtonke=50 Ibs.) <br /> y�G � ��-^ r �/�� � <br /> Grouting Material ���� ��l�C���k6fii � to 1�l.Jft. yards � bags <br /> from to tt. yards bags <br /> from ta 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 No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The infortnation contained in this report is <br /> true to the best of my knowledge. <br /> I�or� Stcxlais Well Drillin�; Co., In�. 1b9I <br /> Contractor Busine Name License or Registra6on No. <br /> `- �f .-�1 tJ� ✓ � <br /> Au "z s e ig t Date <br /> LOCAL COPY r,, , _�. � , ,i,� -v' <br /> H 2 517 4 4 Name o/Person Sealing Well or Boring <br />