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�' t <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH P�linnesota Well and Boring I„' C � <br /> Sealing No. <br /> CountyName WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> ����n Minnesota Statutes,Chapter 1031 or W-series No. <br /> �Leave blank ii not known� <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 06 . � � <br /> GPS Latitude degrees minutes seconds l / <br /> LOCATION: Depth Before Sealing����ft. Original Depth ft. <br /> Longitude degrees minutes seconds pUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑MWtiaquifer ' <br /> 4��oiT A� � Ya n� �C.�L' �E}�-�BORING �Measured ❑Estimated = <br /> P d]LW po u �JLW I-Y�Nater Supply Well ❑ Monit.Well <br /> Show exact bcation of well or boring Sketch map of well or boring ��� //�r ,y, '£ <br /> in section grid with"X" ocati ,showina prooerty ❑Env.Bore Hole ❑Other �fL �below ❑above land surface <br /> ines, oa s,and buildi s. �� <br /> N � ` CASING TYPE(S) <br /> � <br /> -- - -- - -- -- -- � <br /> 'Ok Steel ❑ Plastic ❑Tile ❑Other <br /> W -- - - — - -- --,-- E �p� WELLHEAD COMPLETION <br /> r , � � ��"' Outside: ❑Well House Inside: ❑Basement Oftset ± <br /> -�- —� `- --i— � <br /> ��^�� �Pitless AdaptedUnit ❑Well Pit <br /> —�- -i-- -�-- --i— � �\ ' <br /> ❑Well Pit ❑Buried <br /> S "''''� { ,, � <br /> �—'m"°--_�' � �� f JY� � �'^r+ ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diame r�� Depth ( Set in oversize hole? Annular space initially grouted? <br /> Property owner's ai i g a dress it different than well bcation address indicated above `' <br /> � in.from__�__ t0��ft. ❑Yes f�No ❑Yes ❑No ❑Unknown <br /> T` <br /> in.f�oi71 t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No 0 Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE / <br /> Well ownels mailing address if different than property owner's address indicated above SCf@en ffom��t0��ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS _ <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �o Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed7 ❑Y05 ❑ No DBSCribe <br /> FORMATION <br /> If not known,indicate estimated formaiion log from nearby well or boring PUMP <br /> � "� TYpe <br /> ❑ Removed ot Present ❑ Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Anrular 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 /> ❑ Other <br /> GROUTING MA7ERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> ,.y�,�n/fj� ! <br /> Grouting Material���� �///���✓, rrom_�_to�ft. yards �� 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 No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance wiih Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Dcn3 Stc�odla Well Drilling Co,. Inc. 23172 <br /> Contractor Business Name License or Registration No. <br /> .._ j �� ' .�� ;.,.>� <br /> r d ep sentative-Sign � " Date <br /> `� � .�,r�SY�..l <br /> LOCAL COPY H ��V O i � ���~ <br /> Name of Person Sealing Well or Boring <br />