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� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I � � Q� '� � County Name WELL AND BORING SEALING RECORD MinnfesoNa Unique Well No �`� Minnesota Statutes, Cha ter f03I or W-series No. P _i a� o��k i�o�hnown) Henne in Township Name Township No. Range No. Section No. Fraction(sm.�Ig-) Date Sealed Date Well or Boring Constructed rono 117N 23 8 SV'V 1�W � February 12, 2014 Unknown r� GPS LOCATION- decimal degrees(to four decimal places) p 1 1 g ' Latitude� "�"'�� 5�.��ILongitudeN 1��.�� DepthBeforeSealing . ��o. _ ft. OriginalDepth.______ ft. � -=� AQ IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location �ingle Aquifer Lj Multiaquifer ,�,/ � 1376 NOj'tll Aj']11 DI'1Ve� Orono 55364 ,W�,E!LUBORING ;zqivleasured [�Estimated Date Measured � � �lNater-Supply Well ❑Monit.Well 65 Show exact location oi well or boring Sketch map of well or boring ,. in section grid with"X" location,showing property �J Env.Bore Hole ❑Other ___ _ _.tt. �elow ❑above land surface lines,r ds,and buildings. N CASING TYPE(S) � -'---'---`----'- . ,�/ �< ��,Steel L,Plastic ��._]Tile �J Other_ __._,_____ � "'"- '-�'-- ---�-- ---`-- WELLHEAD COMPLETION � � � � � � ' W ' ' ' E � � � � T S Outside: �_�i Well House �;At Grade Inside: L1 Basement Offset � ---F-----{-- I J .-_ i. - ------ � , , ; ; Miie �� itless A p dUnit ��Buried ❑Well Pit / / � ✓ r , , , , � , Y9.P' da te --�--- --;--- --�-- --�- � �' ❑Buried �.�Well Pit S i Other �-1 Mile� /1 '� ` .,��Other----��--------- - — ------�— �� 7 PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) 1 ldstone Famil Homes Diametep O Depth 1 14 Set in oversize hole? Annular space initially�.g,,r!outed? � Property owner�s mailing address If different ihan well location address indicatetl above _ �in.from_ ._ _ to___.___ft. ��`j Y05 I_ J No J YeS r]No '/rlJnknOwn t 801 Cliff Road East, Suite - 135 � llUI11$Vllle� lvll� JJ33/ __..in.from to ft. I_�Yes []No ❑Yes �j No ��Unknown 8 ;� _ _. _ in.from _ to_..____ ft. [j Yes , i No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE 1 1 O Same Screen from 1 1� to 1 1 O ft. Open Hole from to ft. Well owner's mailing address if different than property owner's address indicated above - - OBSTRUCTIONS ��Rods/Drop Pipe i__j Check Valve(s) ��Debris �-!Fill �No Obstruction Type of Obstructions(Describe)___ ____ ,` GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? -'Yes ' ;No Describe_. FORMATION 9 Y g PUMP Submersible If not known,indicate estimated formation lo from nearb well or borin Clay Brow vpe-- -- -- '� �. Removed ,_I Not Present ❑Other � Clay Gray 3 6 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: � Sand DrOW 6 1 1 o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe �_,]Casing Perforation/Removal � 17 __,.____ in.from to _ft. ❑Perforated J Removed _ in.from_______.,_._to ft. [�Perforated ,��Removed Type of Perforator_.___ � VARIANCE Was a variance granted from the MDH for this well? [�Yes �o TN# GROUTING MATERIAL(S) (One bag of cement=94 I s.,one bag f tonite=50 Ibs.) �O Neat Cement � �� Grouting Material _ . _ _ . from__ . to ft _ _ 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 borin on ro ert � �] ,�/ � g p p y. Yes �No How many? _ Geology From: UN #801663 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. E.H. Renner & Sons, Inc. 1431 : � a� .. _----- _-_ __ _ _ _ _ _ - _ _ _ _ ___ -- _ �: �� Licensee Business Name License or Registration No. � �I.o `� 467 03/28/14 �ceor�ing ta I�N State Regulatian� --� - 9��'��--_- - - -- P- --- _ _ __ ._ ` CerGfied RP enfahve i nafure Cer[ilied Re No. Date Ed enner LOCAL COPY H � � Q,�1 2 9 9 ---- _-- --- ---- y Name ot Person Sealin Well or Bonn � � HE-01434-74 IC#140-0423 5n3�+