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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H � ��� (� � <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennlego a�Unique Well No. � <br /> ����t]p��,(Z Minnesota Statutes,Chapter 1031 °QaW se�ieskNo. <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> arono 117 ?_3 Zl �' S'�T ?�•� r �� !� <br /> GPS LOCATION-decimal degrees(to four decimal places) � <br /> Depth Before Sealing ��� tt. Original Depth ft. <br /> Latitude__ _ Longitude <br /> A�UIFER(S) STATIC WATER LEVEL <br /> Numerical Stre �e ire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer e�n/�n L d <br /> W UBORING Measured ❑Estimated Date Measured.l/�/��_ ��+ <br /> ���r' h:tl I ^v� �l'Orlt'� �?�i�1 �yyater-Supply Well ❑Monit.Well i <br /> Show exac�t location of well or boring Sketch map of w,eJ(�r bo�ng / ,r� �,r{ <br /> in section rid with"X:' location,sho�p��f� ert ❑Env.Bore Hole ❑Other �f'.�*/ ft. /p��below ❑above land surface <br /> N ��line , ds}��n i dings. <br /> CASING TYPE(S) <br /> ; ; ; ; j <br /> --�-----�-----�-----•-- t � <br /> j j ; j f Steel ❑Plastic ❑Tile ❑Other <br /> � � , � ` <br /> --'--- --'----"�-----�-- ELLHEAD COMPLETION <br /> � � � � t W <br /> W : : : : ET <br /> __�___ __�______�__ ___�__ Outside: ❑Well House ❑At Grade Inside: �asement Offset <br /> , , , , 'h Miie itless A p dUnit ❑Buried ❑Well Pit <br /> , , , , � ❑P da te <br /> --�----T---�-- - ' <br /> ❑Well Pit ❑Buried <br /> S <br /> ❑Other <br /> �1 Mile-� �( • ❑Other <br /> 71 ..t' %� �>>R <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � �t Diame ef s � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above L <br /> in.from�� to 22� ft. ❑Yes � I No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes [�No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> t / <br /> Well owner's mailing address i�diflerent than properry owneYs address indicated above Sc�een from�__._-�._to_��ft. Open Hole frOm to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) �f Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe l�.l� /"LI'� t �(//yf/-� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ❑No Describe <br /> FORMATION <br /> PUMP �'} <br /> If not known,indicate estimated formation log from nearby well or boring. Type .,,)�J� (`U�� <br /> �� f }� <br /> �'� Removed ❑Not Present ❑Other _ <br /> METHOD USEDTO 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 /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes �� No TN# <br /> GROUTING MA7ERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite-50 Ibs.) <br /> Grouting Material!v,�^fy/ C 6m�� from E� to <C.. ft. yards� bags <br /> from to R. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATq�.p�G��TI�S�ING Other unsealed and unused well or boring on property? ❑Yes o How many? <br /> tCG G V c�� <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 <br /> M�� O � �`-�, is true to the best of my knowledge. <br /> _E <br /> �r. �t�r?ola t�ell T)rillin;�; Go. I?jc. 158�! <br /> C�T1(OF ORONO Licensee Business Name , License or Registration No. <br /> � �f���� ��. I �� f � <br /> ....�` ,-.' ,. ✓� r <br /> �ertilled F?e�resentative Signature Certified Rep.No. Date <br /> "'� ''_ ,� � J� �.�, � <br /> H �43 C � ��,.,-, .._... <br /> LOCAL COPY .�.: �l,1� � fi Name ol Person Sealing Well or Boring <br /> HE-01434-14 ID#53159 ,.. Sn3a <br />