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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 9 515 6 <br /> Counry Name <br /> WELL AND BORING SEALING RECORD Minneso a�Unique Well No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank�il no�known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> oc�o �.�� 23 2o sE zar� �. mAN 1 � <br /> r <br /> GPS Latitude degrees minutes seconds Depth Before Sealing � ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds A UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer Q <br /> W L/BORING �Measured ❑Estimated Date Measuredy�_�r' <br /> Water-Su I Well � <br /> pp y ❑Monit.Well ,�/ <br /> Show exact loca ion of well or boring Sketch map of well or boring Env.Bore Hole �/� '�,�b ❑above land surface <br /> in section grid with"X." perty ❑ ❑Other ft. elow <br /> lines,roads,and b Idings. <br /> N CASING TYPE(S) <br /> y+ �Steel ❑Plastic ❑Tile ❑Other <br /> , , , , � ��Y <br /> --'--- --�--- ---`-- ---�-- WELLHEAD COMPI.ETION <br /> W ; ; ; ; ET <br /> � � � � Outside: ❑Well House ❑At Grade Inside: �Basement Offset <br /> 'h n4iie �Pitless Adapter/Unit �Buried ❑Well Pit <br /> --;--- --�--- ---�-----:-- I •--� d <br /> ; ; ; ; 1 ❑Burie <br /> S `���"j�Y' j'i.�C�-.-�_.z.� ❑Well Pit ,]Other <br /> �—i Mile� � [_]Other _ <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diame r�� � Depth � Set in oversize hole? Annular space initially grouted? <br /> rope y ow 's mai ing a ress if diflerent than well location address indicated above �in.ffOm �� to�. ❑YeS �o ❑Yes ❑No ❑UnknOwn <br /> in.trom to 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 � j � � <br /> Well owner's mailing address if different ihan property owner's address indicated above SCreen from /v • to�ft. Open Hole from_ to ft. <br /> OBSTRUCTIONS <br /> �ods/Drop Pipe U Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) J�-��'�-�/�- /".��-"— � �umD <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe <br /> FORMATION <br /> PUMP 5 u(3 f-,v r� p <br /> If not known,indicate estimaled formation log from nearby well or boring. <br /> ' /1 Type__ <br /> t"'� ZJ r�emoved ❑Not Present ❑Other <br /> !' <br /> �ME,/THOD USED TO SEAL ANNULAR SPACE BE7WEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> I XNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> T� <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATEFIAL(S) (One bag of cement=9�Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material/V"»�"!`y 4.�-/�'-�f'rom � to �v yards� bags <br /> __ from to ft. yards bags <br /> __ from _ ro 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? [_J Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION � <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.Ttie information contained in this report <br /> RECEIVEDis true to the best of my knowledge. <br /> JU L - 5 2 011 � �todola Well Dci3lic�; Co�._Tr�. �69Y-- <br /> Licensee Busine Name � License or Registration No. <br /> .--- <br /> CITY OF ORONO �- � �� � � <br /> ili pre e ative Signat r� Certilied Rep.No. Date <br /> 29515� � <br /> LOCAL COPY �"� � �'���Y'��" <br /> Name of Person Sealing Well or Boring <br /> HE-01434-12 IC#140-0423 <br />