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�' wELL oR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I f��O��� <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. L � <br /> �+BlAIIepin Minnesota Statutes,Chapter 1031 ��W,�e���� „,�'°-' .;,`� !'`�.-`� <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117N 23W 07 �,. ,. �,. � '/� <br /> % ` �•.� l` ! <br /> � /`� � <br /> GPS Latitude degrees minutes seconds ��� k. On inal De th C �✓' ft. <br /> LOCATION: Depth Before Sealing g' p <br /> Longitude degrees minutes seconds IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 38,�,j'� Cherry Lane �rOQ�t �• W ��ORING Measured ❑Estimated <br /> Water Supply Well �Montt.Well r <br /> Show exact location of well or boring � 3fi Sketch map of well or boring <br /> in section grid with"X" location,shoWing property ❑Env.Bore Hole ❑Other �ft. �below ❑above land surface <br /> lines,roacts;and buildings. <br /> N � ; r�S ,,,._ CASING TYPE(S) <br /> - - - - - -- -- -- i <br /> �' Steel Plastic ❑Tile ❑Other <br /> W —�- -i-- - -- --i— E WELLHEADCOMPLETION F <br /> :; � � � � � Outside: ❑Well House Inside: ❑Basement Offset ; <br /> � <br /> --�- -;-- -,-- --i-- <br /> �^�+ �Pitless Adapter/Unit ❑Well Pit <br /> --`- -i-- -i— --i-- � ' <br /> ❑Well Pit ❑Buried <br /> S Q �� <br /> ��"^A°�" i��'-�- ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � Di ��, �epth � Set in oversize hole? Annular space initially grouted? <br /> PropeAy owner's mailing address if diHerent than we ocation address indicated above �/ <br /> in.ffom to.��ft. ❑Yes p(Na ❑Yes ❑No ❑Unknown <br /> ��� <br /> 6i2-803-3130 <br /> in.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> Well owner's mailing address if diHerent than property owners address indicated above Screen from�t0��`ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe)���j�,_�� Q �Ul1'./:� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ NO DeSCfibe <br /> � FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP � <br /> �`� TYPe <br /> '�"' � Removed ❑ Not Prese t ❑Other <br /> j 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 Pertoration/Removal <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=94 Ibs.,one bag of bentonite-50 Ibs.) �7 :� <br /> Grouting Materia("'��/ �,�/�—��(�L to/�ft. yards '�^^ bags ? <br /> trom 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 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 is <br /> true to the best of my knowledge. <br /> DON ST4DOLA Ti+TELL DRILLING C0. ,: I�tC. 27Y 7Z <br /> Contractor Business ame � License or Registration No. <br /> ` 'r �r ( . E <br /> :/ <br /> th ed p es nt ive ign Date <br /> `"' ,,.,�.... <br /> y/�� � 1�..,i' .._J:'r��.. <br /> LOCAL COPY �..� 2�$*J 2� ` <br /> Name ol Person Sealing Well or Boring <br />