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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � ���}�� <br /> ` WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No. y ` p <br /> County Name <br /> ��p Minnesota Statutes,Cha ter 1031 or W-series No. <br /> nrze�i n P ��ea�e b�a�k���o�k�ow�� <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> �rono l 17 2� 1� �r+�x �d' �d � � <br /> GPS LOCATION—decimal degrees(to four decimal places) � <br /> Depth Before Sealing ��� ft. Original Depth fl. <br /> Latitude Longitude <br /> A� IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ��f,�/� w <br /> , WELLiBORING - Measured ❑Estimated Date Measured .J/�/I tG /?�� . <br /> 14G� ?� ���{�e �'-� ��'rc�rrn 55391 <br /> ater-Supply Well ❑Monit.Well ( <br /> Show exac4 location of well or boring Sketch map of well or boring ti/l <br /> in section grid with"X" lopation,showing proper �Env.Bore Hole ❑Other ft. �below ❑above land surface <br /> ' I' s,roa ,and buil i <br /> N :V,j�-r�� i�� CASING TYPE(S) <br /> --'--- --'--- ---`—---'-- ._..,�._.�.���J <br /> Steel ❑Plastic ❑Tile ❑Other <br /> W _____ __ ___________ _' E _C� <br /> WELIHEAD COMPLETION <br /> ; � � : <br /> __�_____�______�_____r__ �u"�Y utside: ❑W II House ❑At Grade Inside: ❑Basement Offset <br /> T o e <br /> , , , , 'h Miie less A p r/Unit ❑Buried ❑Well Pit <br /> , , , � �Pit da te <br /> --.-----r---�-- ---:_ l : <br /> - ❑Buried <br /> S ❑Well Pit <br /> ❑Other <br /> F—1 Mile--� ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diame r�� i Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if differeM than well location address indicated above �� in.from � to ft. Yes �No <br /> � ❑ ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> RECEIVEDin.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> ., .., �•� ,r I � <br /> Well owner's mailing address it diflerent than property owner's a tlress dicate a ove Screen from !`74 to�ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> CITY OF ORONO �Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obsiructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> 0 � 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 Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br />� in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE <br /> � Was a variance granted from the MDH for this well? ❑Yes o TN# <br /> GROUTING MATERIAL(S) (One bag ot cement=94 Ibs.,one bag oT bentonite=50 Ibs.) <br /> Grouting Material�✓�ry! �����%�from � ' to�ft yards �t7 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 �, Jo How many? g <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 /> non Strx�ola Well Drillint; Ca., Ir�c. 1<,'?l <br /> Licensee Business Name License or Registration No. <br /> __. �� ,,el �f i� � � - 1 �n <br /> �Nli fese tive,,S1g tur Certilied Rep.No. Date <br /> " 3 � ���� �'� r� <br /> LOCALCOPY � <br /> Name of Person Sealing Well or Boiing <br /> HE-01434-14 ID#53159 5/13R <br />