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F <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' `� �P�b f � <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. .-t <br /> Nenne�in Minnesota Statutes,Chapter 1031 °eaW series Na <br /> Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Consiructed <br /> Orora 117 23 07 t�'�t S� S�: �_ � �_ 1 y <br /> GPS Latitude degrees minutes seconds Depth Before Sealing_�5,;7 ft. Original Depth ft. <br /> LOCATION: Longitude degrees__ minutes seconds <br /> AQUIFER(S) STATIC WATER LEVEL <br /> � Numerical Street Address or Fire Number and City ot Well or Boring Location �I Single Aquifer �_�Multiaquifer ! "� ) F j <br /> 417� trvtt[i JII��Q �}r �J�O� 55364 WELVBORING �Measured �_]Estimated Date Measured�! /' f ._,..' _ <br /> �Water-Supply Well ❑MoniL Well <br /> ; Show exact location of well or boring Sketch map ot well or boring - �/�j � <br /> � in section grid with"X:' ation,-sh ing pro n Env.Bore Hole �.',_,l Other ___ �tt. �below �J <br /> ��� �,�� _ above land surface <br /> N r d n Idi s. CASING TYPE(S) <br /> ' --'-- —'-- --`----'— �\ <br /> _ [�Steel ❑Plastic ❑Tile �]Other _ _ <br /> _____ ______ ___ __ ____ �� WELLHEAD COMPLETION <br /> W ET <br /> Outside: ❑Well House [_�At Grade Inside: ❑Basement Offset <br /> .., , , . , Mile itless A p r/Unrt ❑Buried �Well Pit <br /> �� �P da te i <br /> ------ ---------�-- ---:- 1 � <br /> ❑Well Pit I]Buried <br /> S <br /> ❑Other <br /> ��Mile� ❑Other __ <br /> � <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> �r Dia ter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than weli location address indicated a6ove � jn.from 0 to �� ft. ❑Yes �]No ❑Yes ❑No ]Unknown <br /> in.from ta ft. ❑Yes r]No ❑Yes . ❑No �_]Unknown <br /> _in.from to ____ft. ❑Yes [.J No ❑Yes ❑No �I Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above SCreen from_��t0�+.��ft. Open Hole ffom ___to ft. <br /> OBSTRUCTIONS <br /> ,�J Rods/Drop Pipe ��Check Valve(s) �]Debris ; ;Fill ',J No Obstruction <br /> Type of Obstructions(Describe) �,l' �+ �i V c' - <br /> � GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Q;Yes [__]No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. r <br /> l � A.✓ � � TYPe-.�/�� <br /> I,�Removed ❑Not PreseM ❑Other_ <br /> - � METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 2��No Annular 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 MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> �� Grouting Material �`r! � I^ --�-{�' from n4. to +✓-� ft. yards � bags ��� <br /> 1 <br /> ; from to tt. yards bags <br /> from __ tq_ ft. yards bags <br /> OTHER WEILS AND BORINGS � <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �__J Yes �No How many? <br /> RECEIV�D 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 <br /> is true to the best of my knowledge. <br /> F�S 4 -- �Q�3 Ikin Stod�la T�eII nrillin� Co., inc. 16�i <br /> L�censee Business Name J�-�- . License or Registration No. <br /> CITY OF ORONO ' �._ <br /> ,, y ,��� �� t /-jt� /� <br /> % `� . <br /> ��rtiHed Representahve S�gnatur'e Certilied Rep.No. Date <br /> ...��' -> f/'". <br /> " 3 0 ��4° �.�ti.����,� <br /> �ocn�.�o�v ,��._,...�.... <br /> � Name of Person Sealing Well or Bo�ing <br /> HE-07434-13 IC#140-0423 5n2R <br />