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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 312 0 1 <br /> Sealing No. H I <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if 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 07 NR W SR A 13 <br /> GPS Latitude degrees minutes seconds Depth Before Sealing4• ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds <br /> AgUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Locatioon)' 9 Single Aquifer ElMultiaquifer <br /> 4731 North Shoe fir, Orono 55364 WELLBORING Measured [j Estimated Date Measured f'RMk DAY <br /> Water-Supply well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X.' location,showing property ❑Env.Bore Hole ❑Other ' ft. below ❑above land surface <br /> Ii s, oads;an buildings. <br /> N %J' CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> -'-----i------------------ <br /> mile '�'�""��- WELLHEAD COMPLETION <br /> W - ET <br /> �VVIJ Outside: ❑Well House )<At Grade Inside: ❑Basement Offset <br /> 'h ❑Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> ..................... 1 ❑ <br /> 9 ❑Well Pit Buried dq El Other <br /> -1 Miley r„� >i}� ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Colson Custom l2FJ1iiCs Diameter Depth ' Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above "' in.from U tog&ft. ❑Yes Y4 No ❑Yes ❑No ❑Unknown <br /> 216 Water St in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> excelsior, MH 55331 <br /> n.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> r � <br /> Well owner's mailing address if different than property owner's address indicated above Screen from to ft. Open Hale from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill Wo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL F COLOR HARDNESS OR FROM TO Obstructions removed? El Yes EJ No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> Type <br /> Lie'ft ❑Removed XNot Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> XNo 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 MATERIALS) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material",47- from /'to_IRA_ft. yards_j` 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 with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. <br /> 1) StMola Nell Drilling rn-. Inc. 1691 <br /> Licensee Business N. License or Registration No. <br /> } 4-14-13 <br /> i ere enWive SignatureCertified Rep.No. Date <br /> LOCAL COPY H 312016 Jim Antonson <br /> Name of Person Sealing Well or Boring,. <br /> HE-01434-13 IC#140-0423 5112R <br />