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W�LL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I ��O(� 1 WELL AND BORING SEALING RECORD Menneso a�Unique Well No. �, County Name �@j��lepiQ Minnesota Statutes,Chapter 1031 or W-series No. (Leave blank II not known) Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed �, ,, ,, 2 � GPS Latitude degrees minutes seconds Depth Before Sealing �� / ft. Original Depth ft. LOCATION: Longitude_ degrees minutes__ seconds QQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Loca[ion yRSingle Aquifer ❑Multiaquifer '��)�� L/BORING �Measured ❑Estimated Date Measured��j�� F�.4��R �: 800 Foreat l�rm� Lane Orono I�i �Water-Supply Well ❑Monit.Well { Show exact location of well or boring 55364sketch map of well or boring �� . �{ � - wS in section grid with"X" =location,showing property U Env.Bore Hole ❑Other � ft. ��below above land surface lines,roads,and buildings. N CASING TYPE(S) --'--- --'-----`----'- U �4' Steel [J Plastic ,�Tile �Other __ • -'-- -'' " -'--- -- WELLHEAD COMPLETION ' - - ` - --F ' W ; : : : ET � __;__ _,____�__ __�_ ` Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset � , , , , 'h Miie itless A p r/Und ❑Buried �]Well Pit , , , , � �P� da te ' --;----T-- --�-- ---�-- � 1\ � , � � ❑Buried ' ' S ' ' [f Well Pit ❑Other �-i Miie-� ;7 Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diam t� � � Depth � Set in oversize hole? Annular space initially grouted? Properry own s mailing dress�f di erent a w c ad / ,�,,(' �in.from� to � ! ft. ❑Yes �xrvo ❑Yes ❑No ❑Unknown . � in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown _in.from to ft. ❑Yes �]No ❑Yes ❑No ❑Unknown , WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r � Well owner's mailing address if different than property owner's address indicated above SCreen from�_�to�f�_ft. Open HOIe ffOm to ft. OBSTRUCTIONS �tods/Drop Pipe ❑Check Valve(s) L]Debris ❑Fill ❑No Obstruction 7� Type of Obstructions(Describe)�/�� ¢� �C1�,f...�" GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? Yes []No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. /'� � �c TyPe 4.t_...�1-, ��'`�� `--� �� Removed ❑Not Present ❑Other _ , METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe []Casing Perforation/Removal �� in.from to ft. jJ Perforated ❑Removed in.from to R. ❑Perforated ❑Removed Type of Perforator ��Other_ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �„ /�/ ( / f �/� Grouting Material �f�� /f�1'� Yrofi � to /��R_._ yards�/ bags from to ft. yards bags _._ from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. D011 �TODOLA �TBLL DxZLLIPit3 CO.,,. INC-. 1691 -- —_—.__ Licensee Business N e . License or Registration No. ./ � �' .s / 5.5$ `,;,- � Clv Ce "�ed ep sen(ati�Signatu e • Certified Rep.No. Date LGCA!_CCPY �"� ��Q��O ��-^'C� y Name ol Person Sealing Well o�Boring HE-01434-10 IC#140-0423 .. 5i0�q