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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL AND BORING SEALING RECORD Sea�ing No. H 11016 2 <br /> County Name Minnesota Unique No. <br /> Heane in Minnesota Statutes,Chapter 1031 or W-series No. <br /> � (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 11? 23 7 � � � 8/30/96 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> Z�Q1 North Ar� Drive DepthBeforeSealing g� ft. OriginalDepth '��� ft. <br /> Show exact location of well or boring Sketch map of well or boring ApU1FER(S) STATIC WATER LEVEL <br /> in section grid with"X". � `� location, showing property �ingle Aquifer ❑ Multiaquifer <br /> ��� lines,roads,and buildings. <br /> N WELL/BORING �vleasured ❑ Estimated <br /> [�ENater Supply Well ❑Monit.Well <br /> _ _ _Y_ _l__ __l__ <br /> ❑ Env.Bore Hole ❑Other �r� ft. ❑ below ❑ above I nd s�rface;' <br /> W --�- -i-- -i-- --i-- E CASING TYPE(S) 5 � <br /> -r- -�-- -;-- --�-- � �teel ❑ Plastic ❑Tile ❑ Other <br /> %mile ,,,.,__.�_�/�---^-�-� <br /> -�-- -�-- —�-- --�-- � ��_�� CASING � <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> L� S <br /> pl��mi�e� � in.from.�— to�fi_ ft. ❑ Yes [�No ❑Yes ❑No ❑ Unknown <br /> I <br /> PROPERTY OWNER'S NAME in.from to ft. ❑Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> Property owner's mailing address if different than well location address indicated above. in.ffom to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> Screen from��to�� ft. Open Hole from to ft. <br /> OBSTRUCTIO WDEBRIS/FILL <br /> WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill [�No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill <br /> Obstruction/Debris/Fill removed? ❑ Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOG�CAL MATERIAL COLOR HARDNESS OF FROM TO � Removed � Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> d r i f t O �O �No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material ��'++►�-� �++� from �.�_ to�_ ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes No <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 is <br /> true to the best of my knowledge. <br /> Contracto� usmess Name License or Registration No. <br /> ��, 1 �Ji� � �/�,/`:I�/�,— <br /> Authonzed p b`�ntaGve �gn ate <br /> Neme o erson ea mg e I or Boring <br /> LOCAL COPY H �� �. 016 2 <br /> HE-01434-02 10/95R <br />