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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H � r <br /> County Name WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. ��� ��� <br /> Minnesota Statutes,Cha ter 103[ or W-series No. <br /> P aaa�e oia�x i�o�k�ow�, <br /> Township Na e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Oraw 117 23 €Ni SW SW N�i -�, b <br /> , <br /> GPS Latitude degrees minutes seconds Depth Before Sealing ,/� ft. Original Depth fl. <br /> LOCATION: Longitude degrees minutes seconds <br /> ,f1qUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �YSingle Aquifer ]Multiaquifer /�,/► l <br /> 261 Cy�et Place,Orono 55356 N1ELL/BORING �Measured ❑Estimated DateMeasured`SA�+� !}/'+I� <br /> Water-Supply Well ❑Monit.Well f <br /> Show exact location of well or boring Sketch map of well or boring Q,l� <br /> in section grid with"X." location,showing property �_�Env.Bore Hole ❑Other �ft. �below ❑above land surface <br /> N lines,roads,��d buildings. CASING TYPE(S) <br /> --'-----'------`-- ---'-- �"Z��ta <br /> �Steel '�,]Plastic J Tile �I Other _ <br /> --�-----�------�-- ---`-- WELLHEAD COMPLETION <br /> W ; ; : ; ET <br /> .; � � � � Outside: �Well House �_1 A�Grade Inside: �Basement Offset _ <br /> 'h nniie ❑Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> --�-----T----�-- ---%- � <br />-' ❑Well Pit ❑Buried <br /> S <br /> �-1 Mile� � ❑Other ❑Other <br /> f� s...�. <br /> 1�,._l� �Y�. <br /> PR(�f�tT�Y CuQ(N�'�S NAME/COMPANY NANf� (; CASING(S) <br /> rStL aJ8 4� <br /> Diameter � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if diKerent than well location address indicated above �� / � <br /> � in.from �.O to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> in.from b ft. ❑Yes �;No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No [;Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE� <br /> /�Ji f <br /> Well owner's mailing address if different than property owner's address indicated above SCreen from1��o�ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)�L�V/�J+�/? /"sYL s' �/�_/ <br /> GEOLOGICAL MATERIAL COLOR HAflDNESS OR FROM TO Obstructions remaved? Yes !]No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. ` /� <br /> Type J�! PUl�1r-� <br /> C�� ..� D I r��" � ---- - <br /> Removed ❑Nat 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 Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from __to fl. ❑Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other_ <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> . � <br /> Grouting Material/V�p� C�/O�F/�.)I from__S,rL to I� ft. yards_� bags <br /> from to fl. yards bags <br /> __ from to ft. yards bags <br /> OTHEfl 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 <br /> is true to the best of my knowledge. <br /> Uon Stodole WeII Arillin�; co,. Tnc. 1591 <br /> Licensee Business Name License or Registration No. <br /> '" �f - �' i ,� <br /> i resen a e Si n/re Certi�ied Rep.No. Date <br /> �oCAL COPY H 2 914 0 9 �- -.�� ���.�,�-�, <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-12 IC#140-0423 '�,,� 9iosR <br />