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WELL oR BORING LOCanON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' � �
County Name
WELL AND BORING SEALING RECORD Mennesota Unique Well No.
Hermepin Minnesota Statutes,Chapter 1031 or W-series No.
�ieare m�x n m w,ow��
Township Name Townshi No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed
Orono I1� 3 2 1¢ ,,. �,. Z�- tX� 4
GPS Latitude degrees minutes seconds �`/ �
LOCATION: Depth Before Sealing �(.}(�J ft. Original Depth ft.
Longitude degrees minutes seconds pp �FER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Locatlon Single Aquifer ❑MulGaquNer
S� B� � �' O� WELUBORING Measured ❑Estimated
Water Supply Well ❑Mo�it.Well
Show exact location of well or boring Sketch map of well or ring
in section grid with"X" location,showing pr rty ❑Env.Bore Hole ❑Other ft. below ❑above land suAace
lines,roads.and buil gs.
N ` CASING TYPE(S)
- - - - - -- -- -- �l
"a Steel ❑Plastic ❑Tile ❑Other
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W -�- -;-- -;-- --i-- E � ! �„- WELLHEADCOMPLEIION
� � � � � � "`1 Outside: ❑Well House Inside: ❑Basement Offset
�
—�- -;-- -r- --i— � .
�^Yb � � .,�4 �Pitless AdaptedUnit ❑Well Pit
--�- -�-- -�-- --�-- � t`
.�,i� i Y.�" ❑Well Pft ❑Buried
��""w�' ��''�:�. ❑Buried
PROPERTY OWNER'S NAM�+E`/COMPANY NAME��y[�,,� n� CASING(S)
� ��te vG �-7L7—ZtJY� Dia �� � Depth / Set in oversize hole? Annular space initialty grouted?
Property owner's mailing address if diHerent than well location address indicated above �}
in.ffom� t0/ v�- ft. ❑Yes �]No ❑Yes ❑No ❑Unknown
420 N Sth St, SRe 655
��A��j$' r� �C�� in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
1 J`fV
Attnil71i1� in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE �
/ jQ'� /
Well owner's mailing address if ditterent than propeAy owner's address indicated above Screen from • � t0�ft. Open Hole from t0 ft.
OBSTRUCTIONS �
Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction y
,/� �} �,,,�y �
Type of Obstructions(Describe) 1/IJA�...f� /'?��' 9' / "CJ/rH/r �
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YES ❑ NO Describe
FORMATION
If not known,indicate estimated formation log from nearby well or boring PUMP .
,,— ' < Type ��1� i'U/�1 Q
"J �-'�` Removed ❑ Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
/� �u / . ��j/�� /�
Grouting Materiai�"�'� ( �//N=��� from � to J_S:.L_�ft. yards bags
from to ft. yards bags
from to fl. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property7 ❑ Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFlCATION . � �
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is .
tfue to the best of my knowledge. �.
Contractor Business Name License or Registration No.
_._ .
• "--i r .-"'�/ _.,..._.
o epre entative Signafn Date
� H 239041 �":, ..u,,..�..--
LOCAL COPY
Name of Person Sealing Well or Boring