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� <br /> . .,,. _ <br /> , . . . . . <br /> WELL oR BORING LOCanON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' � � <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennesota Unique Well No. <br /> Hermepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> �ieare m�x n m w,ow�� <br /> Township Name Townshi No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> Orono I1� 3 2 1¢ ,,. �,. Z�- tX� 4 <br /> GPS Latitude degrees minutes seconds �`/ � <br /> LOCATION: Depth Before Sealing �(.}(�J ft. Original Depth ft. <br /> Longitude degrees minutes seconds pp �FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Locatlon Single Aquifer ❑MulGaquNer <br /> S� B� � �' O� WELUBORING Measured ❑Estimated <br /> Water Supply Well ❑Mo�it.Well <br /> Show exact location of well or boring Sketch map of well or ring <br /> in section grid with"X" location,showing pr rty ❑Env.Bore Hole ❑Other ft. below ❑above land suAace <br /> lines,roads.and buil gs. <br /> N ` CASING TYPE(S) <br /> - - - - - -- -- -- �l <br /> "a Steel ❑Plastic ❑Tile ❑Other <br /> 'z <br /> W -�- -;-- -;-- --i-- E � ! �„- WELLHEADCOMPLEIION <br /> � � � � � � "`1 Outside: ❑Well House Inside: ❑Basement Offset <br /> � <br /> —�- -;-- -r- --i— � . <br /> �^Yb � � .,�4 �Pitless AdaptedUnit ❑Well Pit <br /> --�- -�-- -�-- --�-- � t` <br /> .�,i� i Y.�" ❑Well Pft ❑Buried <br /> ��""w�' ��''�:�. ❑Buried <br /> PROPERTY OWNER'S NAM�+E`/COMPANY NAME��y[�,,� n� CASING(S) <br /> � ��te vG �-7L7—ZtJY� Dia �� � Depth / Set in oversize hole? Annular space initialty grouted? <br /> Property owner's mailing address if diHerent than well location address indicated above �} <br /> in.ffom� t0/ v�- ft. ❑Yes �]No ❑Yes ❑No ❑Unknown <br /> 420 N Sth St, SRe 655 <br /> ��A��j$' r� �C�� in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 1 J`fV <br /> Attnil71i1� in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � <br /> / jQ'� / <br /> Well owner's mailing address if ditterent than propeAy owner's address indicated above Screen from • � t0�ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS � <br /> Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction y <br /> ,/� �} �,,,�y � <br /> Type of Obstructions(Describe) 1/IJA�...f� /'?��' 9' / "CJ/rH/r � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YES ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP . <br /> ,,— ' < Type ��1� i'U/�1 Q <br /> "J �-'�` Removed ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 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 /> /� �u / . ��j/�� /� <br /> Grouting Materiai�"�'� ( �//N=��� from � to J_S:.L_�ft. yards bags <br /> from to ft. yards bags <br /> from to fl. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property7 ❑ Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFlCATION . � � <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is . <br /> tfue to the best of my knowledge. �. <br /> Contractor Business Name License or Registration No. <br /> _._ . <br /> • "--i r .-"'�/ _.,..._. <br /> o epre entative Signafn Date <br />� H 239041 �":, ..u,,..�..-- <br /> LOCAL COPY <br /> Name of Person Sealing Well or Boring <br />