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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H <br /> County Name <br /> WELL AND BORING SEALING RECORD <br /> 1551 Li 5 <br /> Sealing <br /> a Unique No. <br /> Hennepin Minnesota Statutes,Chapter 1031 of W-series No. <br /> (Leave blank M not known) <br /> Township Name Township No. Range No. Section No. Fraction(Sm.i.1g) Date Sealed Date Well or Boring Constructed <br /> Orono 118 22 35 , W 8/`26/99 <br /> Numerical Street Address or Fire Number and City of Well or Bonng Location s <br /> 845 Old Long Lice Rd Orono Depth Before Sealing 140 h. Original Depth 140 ff. <br /> Show exact location of well or boring 11 Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with'X'. location, showing properly Single Aquifer 0 Multiaquifer <br /> lines,roads,and buildings. <br /> N WELL/BORING a Measured 0 Estimated .. <br /> l I I Water Supply Well 0 Monit.Well <br /> `-T---T---Y---Y-_ <br /> I I I ❑ Env.Bore Hole 0 Other 73 ft. 4below 0 above land surface <br /> -r — ;- - i-- i <br /> W I 1 I J E CASING TYPES) <br /> --+----i----i----i--- TX Steel 0 Plastic 0 Tile ❑Other <br /> I I I I <br /> — i i i 1 <br /> I CASING <br /> 11111 Diameter Depth . Set in oversize hole? Annualar space initially grouted? <br /> r ruse �S h f4 6 in.from 0 to 36 n. ❑Yes No 0 Yes 0 No 0 Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. 0 Yes ❑No 0 Yes 0 No 0 Unknown <br /> Department of Natural Resources <br /> Property owners mailing address if different than well location address indicated above. . in.from to ft. . 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> ®ttn z Larry Watson SCREEN/OPEN HOLE <br /> 2300 Silver Greek Road HR 136 140 <br /> Roch$i ter: MN 559Q6 Screen from to ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME <br /> Rods/Drop Pipe ❑:crack Valve(s)::'❑Debris' 0 Fill-__,0 No-Obstruction <br /> WN owner's meting address if different than property owners address indicated above. Type of obstructions(Describe) pump' pipe wire <br /> Obstructions removed?.-- '[ Yos -❑No: =Describe <br /> PUMP <br /> Type submersible <br /> HARDNESS OF 4 Removed 0 Not Present 0 Other <br /> GEOLOGICAL MATERIAL COLOR FORMATION FROM TO <br /> H not Known,indicate astlms4d formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ANo Annular Space Exists <br /> drift 0 140 0 Annular space grouted with tremie pipe <br /> I 0 Casing Perforation/Removal <br /> • in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> • <br /> Type of perforator <br /> 0 Other <br /> GROUTING MATERIALS) t *s <br /> Grouting Material Portland fro,,, 340 to 0 n t 25 <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards begs <br /> REMARKS.SOURCE OF DATA,DIFFICULTIES IN SEAUNG OTHER WELLS AND BORINGS ,�['' <br /> Other unsealed and unused well or boring on property? 0 Yes L!No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed In accordance with Minnesota Rules,Chapter 4725. The Inforrtlsbon contained in this report is <br /> true to the beet of myatnbwledg: ' <br /> - . SIRS Well Drilling 27276 <br /> Contractor Business Name llosrns.ril2. <br /> l <br /> `/x"11 <br /> • <br /> AUHortzed Representative Signature Data <br /> 1t �. <br /> �: Rob Stodola <br /> LOCAL COPY - H '155105 Name of Pelson Sealing Well or Boring <br />