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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL OR BORING LOCATION <br /> WELL AND BORING SEALING RECORD Sealing No. H l 3 <br /> County Name Minnesota Unique No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin 'Leave blank II not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-s,lg.) Date Sealed - Date Well or Boring Constructed <br /> Orono _ 117 23 02 321-0OOP /) '906 99 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ,, / 2 t 1 <br /> 485 Orono Orchard Rd! Orono Depth Before Sealing It. Original Depth n. <br /> Show exact location of well or boring (3 Sketch map of well or•. UIFER(S) STATIC WATER LEVEL <br /> in section grid with X. : . .. . ` Single Aquifer 0 Multiaquifer <br /> lines,roads,and buildi <br /> N g_ WELL/BORING k Measured 0 Estimated <br /> ,` <br /> I `�ye`, Water Supply Well 0 Monit.Well <br /> '-T-`-T- -Y-`-l-" <br /> • <br /> ` t W <br /> 0 Env.Bore Hole 0 Other �` • ft. below ❑above land surface <br /> W E `vi <br /> i CASING TYPE(S) <br /> -__)--_4_-4____l-_. I �_ e )(Steel ❑Plastic 0 Tile 0 Other <br /> I I I I u rove I ' CASING <br /> ---;----1----+---i--- I 1 <br /> 1 .4. Diameter ,.{ Depth f Set in oversize hole? Annualar space initially grouted? <br /> � S <br /> l <br /> I f mat--11114 ,G in.from Z2_—_ to 707 h. 0 Yes *No 0 Yes 0 No 0 Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑Yes ❑No 0 Yes 0 No 0 Unknown <br /> Yerigan Construction <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. 0 Yes ❑No 0 Yes ❑No 0 Unknown <br /> 27741 University Ave NTE SCREEN/OPENHOLE { <br /> Iaant i s RPite*lj 55040 Screen from Xi g to If ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME C ^I" Rods/Drop Pipe ❑Check Valve(s) 0 Debris 0 Fill 0 No Obstruction <br /> Weil owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) Mor Ir/1. 4 CY/ ` OE i <br /> I <br /> Obstructions removed? Xfes 0 No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO 0 Removed Xr Not Present 0 Other <br /> FORMATION METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> It not known,indicate estimated formation log from nearby well or boxing. <br /> ,yr No Annular Space Exists <br /> drift l t - . ❑Annular space grouted with tremie pipe <br /> 1❑Casing Perforation/Removal <br /> • in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) ,,,,,,� � / <br /> Grouting Material ` `fitit} trom if to ZIl ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS y� <br /> Other unsealed and unused well or boring on property? 0 Yes I�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 is <br /> true to the best of my knowledge. <br /> yti'�$�, na We ii ing Co„.„, Rag�172 <br /> GOrtIaLTOf � Dc �, 8-18--99 <br /> t .:- dative ' furs <br /> , Date . <br /> Jim Antcnaon <br />