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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 0 9 6 4 5 County Name WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No. Minnesota Statutes,Chapter 1031 or W-series No. ��enne in (Lsave blank it not known) Township Name Township No. Range No. Section No. Fradion(sm.�Ig.) Date Sealed Date Well or Boring Constructed ° Orono 1�7 23 �7 S�9 �; S'� 10 ,� � . GPS Latitude degrees minutes__ seconds Depth Before Sealing � ft. Originaf Depth ft. LOCATION: Longitude degrees minutes____ seconds 11QUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Mu,iaquifer �/ nf',/ W LBORING J�I Measured [�Estimated Date Measureds�(�'n/ 12�5 ,�'.��'iT4i�C)()(� AV�� '� �Water-Su I Well � pp y ❑ onit.Well Show exact location of well or boring Sketch map of well or boring �. in section grid with"X" location,showing property - � ;Env.Bore Hole ❑ ther �� fl. �below ❑above land surface lines,roads,and buildings. ' N � CASING TYPE(S) --'-----i-- --'-----'-- �, � �i �/1$teel �.�Plastic [] ile ❑Other _ _ ,' � {��^^''''(( A, '� '-- --- ---` `-- ..._._,_I� :��. WELLHEAD COMPLETIO ' W � � � E ,. , T � �: � � � � ;,Outside: �_.J Well House ❑At Grade Inside: �Basement Offset - - 1 'h iie �� ❑Pitless Adap dUnit ❑Buried �Well Pit 1 C ❑Well Pit L�Buried ' ' S ' - � ❑ome� _ �----1 Mile� ❑�IhOf___ _ PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Jftson �l�[ Di et�r ' Depth � Set in oversi e hole? Annular space initially grouted? Property owner's mailing address if different than well loca�ion address indicated above �?�� .� !]UnknoWn �, in.from �._._ to_G�C _ft. ❑Yes �No ❑Yes f No , 8�53 E Aloan3.nt;tan Free�ray _ J in.from to ft. ❑Yes ;]No i. I Yes I 1 No ! �Unknown �C� �� Blaomington, ��'T 55G20 in.from to ft. ❑Yes ❑No �]Yes []No �]Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE e/,.�1,(�+ � Well owner's mailing address it ditterent than properry owner's address indicated above Scfeen ffom '�-`��to �O ft. Open Hole from to _ft. OBSTRUCTIONS �'. �Rods/Drop Pipe ;�Check Valve(s) ❑Debris [;Fill []No Obstruction Type of Obstructions(Desc ibe) l/1/�� /'l F�' 4- ;,T�/ _ GEOLOGICAL MATERIAL COLOR HARDNESS oR FROM TO Obstructions removed? Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log trom nearby well or boring. �,... ' � r�� TYPe i, ,i_� � �Remaved � ot Present ❑Other METHOD USED TO SEAL NNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: I�No Annular Space Exist �_'Annular Space Grouted with Tremie Pipe [�Casing Perforation/Removal ` ._ .___in.fro to ft. [l�.Perforated ❑Removed � in.fro to _ft. �,',Perforated �i Removed Type of Perforator [�Other---_,-- GROUTING MATERIAL(S) � (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) � �`', i . e7 � Grouting Material�'�',J�/� C�++r�+�+� from cG to`�� ft.__, yards�_ bags ___ from to ft. yards ___ bags __ __ from to __ ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES W SEALING Other unsealed and unused well or boring on property7 [;Yes No How many?_ LICENSED OR REGISTERED CONTRACTOR CERTIFICATION ��R�'��D This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report V is true to the best of my kno�vledge. FEB 4— 2013 � scoa�� ISe1l. Drillirts C,o., r�. z�Q� Licensee Business N me License or Registration No. ff CITY O�ORONO _ --,� f � f - / � - 1.� , ��, � , ifie0 Represenfative Si n�hire Certified Rep.No. Date . .- �. �OCAL COPY H � — ---- ti�-�- Rf� �s �iC�Y��..+ _ 3 0 9 6 4.� Name of Person Sealing Well or, oring HE-01434-13 IC#140-0423 5n2R ¢