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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„� '� >. WELL OR BORING LOCATION WELL ANU BORING SEALING RECORD Menn'ego a�Unique Well No. y � �' County Name �e�� H�err�Q�h Minnesota Statutes,Cha ter 103i or W-series No. P leave blank f,�o�known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed � � Date Well or Boring Constructed . ° Orono 117 23 17 SFd S�7 � ` I �_! _ /:� _ GPS LOCATION- decimal degrees(to four decimal places) ;�'",. Depth Before Sealing �-� ft. Original Depih fl. Latitude __ Longitude _ A UIFER S STATIC WATER LEVE � �- - � ` 'F.,�O [�Sln le(A)uifer Multia uifer �� %y �� .! Numerical Street Address or Fire Number and City of Well or Boring Location 9 4 ❑ 9 J 3 5 3 F� L�r1C �i�� F1Q WELUBORING �Measured ❑Estimated Date Measured � _ � ',�Water-Supply Well ❑MoniL Well �� ' Show exact location of well or boring Sketch map of well or boring � � '� in section grid with"N:' location,showing proper�ty C�Env.Bore Hole ❑Other �' ___ft. �1 below ��above land surface lines.roads,and buildin s. pSINGTYPE(S) ' --'-- --'-- --`-- ---'- � � �Steel `',��Plastic �;Tile ]Other_ ___ � � � � � F .� --',-----i-- --�- --l-- WELLHEAD COMPLETION �z 9 � W � � � � E T utside ell House ' t Grade Inside: �Basement Offset � --�-- -;-----�-- ---*-- I --W ` .. O ' : -�� ` A I . I I 1 1 ..----. 'h Miie ��Pitless Adapter/Unit �J�Buried �J Well Pit � � , : � � ;--- � -�- -�-- %� �]Buried ❑Well Pit �; S �Other ��t.w E =??�L � �—t Mile� '� l�(�,�-,,r,.,i =�..a_ri8-� n Other `�,l �i PROPERTY OWNER'S NAM�iCOMPANY NAM CASING(S) Fri t z �,il�i cxson Diameter Depth� Set in oversize hole? Annular space initially grouted? Property owners mailing address it diflerent ihan well location address indicated above ��in.from �l__ to �J� ft. ;�Yes �ycrv0 �Yes ❑No L�Unknown ( 3'�!-a3 Cr�rstal Pla�e in.from to ft. I�Yes �!No ❑Yes '�No � �Unknown � ?'m? 55391 �rOI�D in.Gom to ft. '�Yes '�No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE 9 Well owner's mailing address it different than property owner's address indicated above SCreen from____�� to f V (t. Open Hole from to _ ._.____ft. ,��- OBSTRUCTIONS �Rods/Drop Pipe ��Check Valve(s) !,_]Debris ;J Fill �No Obstruction Type of Obstructions(Describe) `�.Jr '�-w�y^ ��3 �r'��.. _ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �Yes ❑No Describe_ FORMATION PUMP � If not known,indicate estimated formation log from nearby well or boring. � p � Type �j�:,l�-.�.�..s--v"""A`rva.�'..K,y''."�" `�' f'� �� /D [�I Removed �Not Present ❑Other___ � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists ��Annular Space Grouted with Tremie Pipe L-�Casing Perforation/Removal __ ' in.from _to_________ __,_____ft ��Perforated ]Removed :- . in.from ___________to __ ft. ❑Perforated [�Removed �� Type of Perforator ` VARIANCE Was a variance granted trom the MDH br this well? ��__�;Yes �No TN# __ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material � �_9'1"r`�`�`�'� from l,�_ to /Cl ft.__. .__ yards�J bags r _ trom to fl. 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? i�;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. I)on �to�ola �t 11 ncillin�_Co�_._Inc. 1b91 Licensee Business ame License or Registration No. 1� r� �//� / '� �--._-- _J. l'c� - F� _-... e�''d �r�se tive Signsture� Certified Rep.No. Dafe H -- -- ��-r-.--'��1._..-�_� _.--� --- -- LOCAL COPY �2�4 4 2 Name of Person Sealing Well or Boring HE01434-14 IC#140-0423 5n3R