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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 4 9 County Name ,-1NELL AND BORING SEALING RECORD Mennleso a�Unique Well No. {t Minnesota Statutes,Chanter 103/ or W-series No. N'�nDe!"1�D Y (Leave blank il not known) s �� Township Name Township No. Range N��.iSection No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Orono 117 2� �0 N�T SE 'S IZ G? — � GPS Latitude_ _ degrees __ minutes____ seconds Depih Before Sealing�__k. Original Depth ft. � LOCATION: Longitude____ degrees______ minutes_ _ seconds AQUIFER�S) STATIC WATER LEVEL � Numerical Sheet Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer �/' � WELL/BORING �!�leasured ❑Estimated Date Measured � 2623 Casco PAfnt g� �rOn0/ � ater-Supply Well ❑Monit.Well � Show exac[location of well or boring 5539�ketch map of well or boring = � _�[,/� _ ky[ - in section grid with"X." —t cation,showin property _ I Env.Bore Hole Other 7._� ft ��,elow [�;.above land surface N �1� ti road an wi ngs. CASING TVPE(S) ._ --'--- --'--- ---`-- --`— �. �teel ,_�,Plastic ❑Tile ']Other �� '-'"- --�--- ---�-- ---�-- � WELLHEAD COMPLETION � ` W ' ' ' ' ET G d I d Off � ��► _ '� , ,. __; _ _,___ _;_____r__ Outside: ❑Well House �_J At ra e nsi e: '��,_ Basement set • " ' ' ' ' • - ell Pit ' , , , , 'F M�'e �itlessA ptedUnit �Buried U W ;. , , � da : --;-----,--- ---�-----:-- 1 � �� , , , , ❑Buried ' ' S ' ' ❑Weil Pit ❑Other �-1 Mife� ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diam�tej� t Depth � Set in oversize hole? Annular space initialty grouted7 Property owner's mailing address i ifferent ihan well ocanon a re s i i �e above _L� jn.from � to_�_2_ft. '�]Yes �lo ❑Yes ❑No ❑Unknown sa�� a� �b�0� in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown 952-ao�-saio in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � / Well owner's mailing address if different than property owner's address indicated above SCreen from�to�R. Open Hole from to ft. � j OBSTRUCTIONS �. / �p� ��ynods/Drop Pipe ❑Check Valve(s) ❑Debris j]Fill [�No Obstruction /� TypeotObstructions(Describe),�R,(�JJ�-� �/�� q- �bI/��'! T' GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obshuctions removed? [_ es I No Describe FORMA710N — PUMP Q If not known,indicate estimated formation log from nearby well or boring. Type J V� I"{j�/YtJ�7 c� �"r - �emoved - ❑Not Preserk ,._l�.Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: ^ ❑No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe (�Casing Perforation/Removal in.from to ft. ;�Perforated ❑Removed in.from ro ft. ❑Perforated ❑Removed Type of Perforator _. i ❑Other___.----------- �. GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) a /y �/� Grouting Material ��f/1��'fr6m to ft. _ yards._� bags __ _ from to ft. yards.._ bags from to. ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEAUNG Other unsealed and unused well or boring on property? ❑Yes � o How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. DOId STODOLI! WSLL DBILLING CO. ,. INC. 1691 __ _ _ _ _- - - -- __- -_ _ , Licensee Business Name License or Registration No. .�_ - i�4�� ` 558 1�`-�a7 O�j '. _ _ _ _-- _— -- Ce ed e esentative Signature Certified Rep.No. Date ' , -- — — � H 27549 6 �` �, � ,.y�� ` Lii:;��_COPY Name of Person Seahng Well or Boring ' � i HE-01434-11 IC#140-0423 2loaa