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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> Sealing H 107812 <br /> County Name WELL AND BORING SEALING RECORD to <br /> Minnesota Uni ue No. <br /> Minnesota Statutes,Chapter 1031 or W_, <br /> Minnesota <br /> Herne n (Leaveblan i oJC�1111 <br /> Township Name Township No. Range No. Section No. Fraction(sm.-).Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 1177 9,; is <br /> JAN 3 01997 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> Depth Before Sealing —ft. GIDITYEOF-CRONO—ft. <br /> Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X'. location, showing property -Single Aquifer E] Multiaquifer <br /> lines,roads,and buildings. <br /> N WELLIBORING ❑ Measured ❑ Estimated <br /> Water Supply Well ❑Monit.Well <br /> ❑ Env.Bore Hole ❑Other 7, —ft. below Elabove land surface <br /> W --�- -�-- --�-- --i-- E CASING TYPE(S) <br /> Steel E] Plastic E]Tile ❑Other <br /> v mile <br /> -I-- --�- -- -- --�-- CASING <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> pIIy� S <br /> mite 2"""��J��� A^f <br /> t in.from to—� ft. ❑ Yes No ❑ Yes ❑ No Unknown <br /> PROPERTY OWNER'S NAME in.from _ to— ft. ❑ Yes E] No No E] Yes ❑ No ❑ Unknown <br /> Property owner's mailin s nt 'o dress indicated above. in.from to_ ft. ❑ Yes ❑ No ❑Yes ❑ No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> 225 Tonka Ave. <br /> Screen from��to�� ft. Open Hole from to ft. <br /> Orono, MN 55356 OBSTRUCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill- No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill <br /> Obstruction/Debris/Fill removed? ❑ Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed E] Not Present E] Other FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �. No Annular Space Exits <br /> Annular space grouted with tremie pipe <br /> ❑ 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) <br /> Grouting Material Ne(I t _ iT�11 tom �— to 4)1— ft. yards 2 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 UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes No <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 /> c3biii Narilling & Env. e T v C e Wense n No. <br /> Authorized Representative Signature t <br /> dirk stevens <br /> LOCAL COPY TH 107812 <br /> tlO7812 Name of Person Sealing Well or Boring <br /> HE-01434-02 <br /> 10/95R <br />