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CITY OF ORONO CALLED IN l/
INSPECTION NOTICE QSCHEDULED /• OD
PERMIT NO d �O��U COMPLETED
ADDRESS 7D� /�S< ,��C(��
OWNER CONTR.
TELEPHONE NO. ��✓� - ��� � l
� DESCRIPTION �'
� ❑ FOOTING ❑ MECH NICAL RI ❑ EXCAV/GRADING/FILLING
Q ❑ FRAMING ❑ MEC ANICAL FINAL ❑ IAKESHORE/WETLANDS
y ❑ INSULATION ❑ WOOD BURNER/FIREPLACE
O ❑ TREE REMOVAL
Z ❑ WALL BD. ❑ WATER HOOK-UP ❑ SITE INSPECTION
Q ❑ FINAL ❑ SEWER HOOK-UP ❑ PROGRESS
� ❑ DEMO-SITE ❑ SEPTIC MAINT. ❑ COMPLAINT
� ❑ DEMO-FINAL ❑ SEPTIC INSTALL. ❑ FOLLOW-UP
i ❑ PLUMBING RI ❑ SEPTIC FINAL ❑ HARD COVER REMOVAL
v ❑ PLUMBING FINAL ❑ FOUNDATION/REMOVAL
� OWNER/CONTRACTOR TO MEET YOU:_YES_NO
� COMMENTS:
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W� �WORK SATISFACTORY:PROCEED ❑ PROJECT COMPLETE
W ❑CORRECT WORK&PROCEED ❑ ISSUE CERTIFICATE OF OCCUPANCY
O ❑ CORRECT WORK,CALL FOR REINSPECTION TEMPORARY
V BEFORECOVERING PERMANENT
❑CORRECT UNSAFE CONDiT10N WITHIN HOURS. ,� pHOTO TAKEN
INSPECTOR WILL RETURN
❑STOP ORDER POSTED.CALL INSPECTOR �CITATION ISSUED
❑ INSPECTION REQUIRED.CALL TO ARRANGE ACCESS.
Call forthe next inspection 24 hours in advance. �952� 249-4600
OwnerlContractor on site:
Inspector. �
White Copyllnspector's File Canary CopylSite Notice
i WEL!OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H '1 "j )
County Name
WE�L AlVD BORING SEALlNG RECORD Mnnle9oaoUniqueWellNo. )
H e n n e p i n Minnesota Statutes,Chapter 1031 or W-series No.
� ���a�o�,�;,�o,.��m,
Township Name Township No. Range No. Sectior,No- Fraction(sm.�Ig.) Da1e Sealed Date Well or Boring Constructed
Orono 1 1 7 23 22 'u �4 NU� 10-21 -08
. GPS Latitude � degrees_ minutes._ seconds Depth Before Sealing 18 4 fl. Original Dep1h �l_
LOCATION: Longitude degrees_ minutes seconds
AOUIFER(S) STATIC WATER LEVEL
Numerlcal Street.4ddress or Fire Number and Ciry of Well or Bonng Location Xl Single Aquiter G MWtiaquifer
7�� B i g I s 1 a n d � �r�n� � WELVBOfiING [�Measured ❑Estimaled Date Measured
� ��Waier-Supply Weil :_`_i Monit.Well
Show exact locahon of well or boring Sketch map of v�ell or boring �,
'in section grid with"X" location,showing properry ❑Env.Bore Hole `,Ofher ��ft. �below U above land surtace
-� � lines,roads,and buildings. CASING TYPE(S)
N
_"_'_ "_�" ""_''_"'"' .
�j Steel ❑Plastic iJ Tile ❑Other
� � � � -� WELLHEAD COMPLETION
W ; ; � � ET -
_.;.__ ' ' ____y_. Outside: ��]Well House i�A1 Grade Inside: I_'�...Basement Otfse�
� , � � 'h Milo II Pi
' ' ❑Pilless AdapledUnii ❑Buried �i_i We 't
--:-----r-----.- ---:- 1 ,�
� Well Pit ❑Buried
, 5 � ,
� ❑Other
�--i M�ie—� ❑Other
PROPERTY OWNE S NAM /COMPANY NAME CASING(S) �
B r i a n �3 o t�i a m Dia�eter G Depth� O O Set in oversize hole? Annular space initiaily grouted7
Pmperty ov+n[!rs mailing adtlress II tlitferent Ihan weli location adtl�ess Intlicated above
� � in.irom U to U fL �Yes [�No �Yes ❑No ❑Unknown
387 Margaret Circle
W a y z a t a , M N 5 5 3 91 ___��.��om_ �o___ft. ❑ve5 �.�No ❑Yes ,:�No r_���k�oW�
_in.Irom . to_ _tt. ❑Yes _!No ❑Yes ❑Plo ❑Unknov✓n
I WELL OWNER'S NAf�1E/COAdPAiJY�JAME SC�SEcN/OPcN HOLE
Same 1p/�
Well owner's.nailin^y aCdross�il�il;erent II-�,-,n pr�pyrty p�=;r.er s adUress inC�iw�ed above �Cl2?�irom�Q____IG__LV�} f;. Oeen HCIe 1fGT.___ to ft.
OBSTRUC710NS
�X;aedslDrop Pipe ���Check Vaive{s) ❑Debns '. F��II ;No Obstructior.
T,-Fe�f obs«��;,o�s,oes��,be, 1 Y4" D r o p_�p e & p a c k e r j e t
GEOLOGICAL PdATcRIAL COLOR I HARDNESS OF I FflOfvi� TO Obslrudions remov=_d?x�(Yes J�No DescribA �
I FORtr1ATION � I
-{PU�:1P
II not!cnev.�^,,inCiCate e5limated iormalion log`rom nearbv riell or borr,g. r. . e+
C Typ2 U� t,
C 1 a y y� w M e d � 4`� Xi Removed '�;Not Present I—,Olher
II — —_____— ---
� I 4 5 I O ���THOD USEDTO SEAL ANNULAR SPACE BETWtc�2 CASINGS,UR CASING AND BORE HOLE:
��Mu Annular Space cxis;s �_i Annular Space urouted�.vith Tr2mie ripe ��_j Casin PerlorationiR?moval
Clay , Sand Grey Med � 80 , 13 - 9
I i � ---------.in.irom_------ to__. _1L !_j Pzrforated J'.Removed
Sand Gra � Soft 136 180 ` I
. —_____ in.from ________�o__ .ft. f_)periorated I._j Removed
� Npe of Periorator _----- ------
'^�;Oth��_ _ �
GROUTING MATERIAL(5) (One 6ag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material_��']__S_Q 1 1 � trom�j to�_�� ft. __ yards__�_ bags
& Bentonite
from to__ ft. _ yards bags
irom to ft. yards bags
OTHER WELLS AND BORINGS
REIviARKS,SOURCE OF DATA,DIFFICULTIES IM SEALING Other unsealed and unused well or bonng on property? ❑Yes �j No How many^
G e o 1 o t a k e n f r o m n e w �^f e 1 l 0 n LICENSED OR REGISTERED CONTRACTOR CERTIF!CATION
9 Y This wali or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
S i 't e . is true to the best of my knowledge.
M N U I V Q # 4 614 7 0 Co c or Busines N n C� Llcense or R g toion N�o.
_ 1101
Certilied Representative Signature Certified Rep.No. Date
H � ° � Ron Danielson 10-21 -08
:�i'JiV '� . 'i UF N�-_. TH r�:iP'/ �;��i
�� � �-- Name ol Person Sealing Well or Boring
HE-01434-09 IC#740-0423
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