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WE1�oR BORING LOCA7loN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I <br /> Counry Name <br /> WELL AND BORING SEALING RECORD Minnle oNa Unique Well No. <br /> Minnesota Statutes,Chapter 10.?I or W-series No. <br /> (Leave dank H not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> orono 117 3 os 15 .,. .,. UG <br /> r <br /> GPS Latitude degrees minutes seconds �� <br /> LOCATION: Depth Before Sealing "^"' ft. Original Depth fl. <br /> Longitude degrees minutes seconds ppWFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location p Single Aquifer ❑Multiaquifer <br /> 1 t,�A �w �{� WELUBORING �v1easured ❑Estimated <br /> KJV \.e[IC ltt �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. (�pelow ❑above land suAace <br /> N c,f lines,roads,and buildings. CASING TYPE(S) <br /> - - - - - -- -- �, <br /> �Steel ❑Plastic ❑Tile ❑Other <br /> W -- - -i-- -i-- --i— E �t WELLHEAD COMPLETION <br /> r � <br /> --r�.� <br /> Outside: ❑Well House Inside:�Basement Oftset <br /> —�- ---- -;-- --i-- � ��: �� <br /> 1��� ❑Pittess Adapter/Unit ❑Well Pit <br /> --�- -�-- -i-- --i-- `� <br /> � � � ' 1�, ❑Well Pit ❑Buried <br /> �—"^�w—#` .._f �Buried <br /> P��p/PE�[�RiT�Y OW E 'S NAME/COMPANY NAME CASING(S) <br /> •�o"� & ��$1� ILl�• Diameter � Depth � Set in oversize hole? Mnular space initialty grouted? k <br /> Property owner's mailing address it different than well location address indicated above � � / <br /> � in.fromS� t0�ft. ❑Yes �Vo ❑Yes ❑No ❑Unknown <br /> 2518 �scu Poic�E Rd <br /> sv��ta! � Tj�3�1 i�.from t0 ft. ❑Yes ❑No �Yes ❑No ❑Unknown <br /> t <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> t t <br /> Well owner's mailing address if different than property owners address indicated above Screen from�f0�ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill �j No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑YeS ❑ NO DeSCfibe <br /> FORMATION <br /> N not kqown,indicate estimated formation log fiom nearby well or boring PUMP <br /> p.._ <br /> � � ^� TYPe <br /> ❑ Removed /�Not Present ❑Other <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 Perforatlon/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 ot bentonite=50 Ibs.) <br /> Grouting Material�l��.f-���%+�' from �� ' to�ft. yards � bags <br /> from 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 infortnation contained in this report is <br /> true to the best of my knowledge. <br /> tkyn Stcxiola t�ell Drilifng Co, Tnc� I692 <br /> Contractor Bu hes ame License or Registratlon No. <br /> { �,�/I �,_..r �� <br /> tho d resen a ve Si n re Date <br /> _., a <br /> F � <br /> H 2 5 0��fi A_... ;� � .,.� ,,.._ <br /> LOCAL COPY �"' '."" <br /> Name of Person Sealing Well or Boring � <br />