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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„' r� �^ <br /> County Name <br /> WELL AND BORING SEALING RECORD M nneso aoUnique WeII No. <br /> Minnesota Statutes,Chapter iO3! or W-series No. x <br /> (Leave Wank ii not known) <br /> H�� <br /> Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed _ <br /> (� � � ,�i'� „ ' <br /> GPS LOCATION-decimal degrees(to four decimal places) CITY OF ORONO <br /> Depth Before Sealing ft. Original Depth ft. <br /> Latitude Longitude <br /> A IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> �{ 'T � � �. 7� W UBORING Measured ❑Estimated Date Measured <br /> l 7� OCttil �C�"? C CC)?1f} �� >���s <br /> Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or b rin <br /> in section grid with"X:' location,showing prop ty., ❑Env.Bore Hole ❑Other �tt. �'�elow ❑above land surface <br /> N lines,roads,and buildi s.;:, CASINGTVPE(S) <br /> ` <br /> _ --'-- --i-----`-----'-- ' �� <br /> i �X Steel ❑Plastic ❑Tile ❑Other <br /> > _,___ __a___�_____;__ WELLHEADCOMPLETION � <br /> W : : : ; ET � <br /> � � � � Outside: ❑Well House ❑At Grade Inside: Basement Offset <br /> 'h Miie Buried ❑Well Pit <br /> � . <br /> �.. ; T ' ; itless A p r/Unit � uried <br /> 1 � ❑P da te <br /> ; ; ; , \" �]we��Pit ❑s <br /> , S +�� ❑Other <br /> ,: ��nniie� \�3 ❑Other <br /> 3 S <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � �J r G Diameter Dept Set in oversize hole? Annular space initially grouted? <br /> Properry owneis mailing a dress if different than well location address indicated above �in.frOm_� to�ft. ❑Yes �No ❑Yes ❑No L]Unknown <br /> ? in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> h WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if different than properry owner's addiess indicated above SCre2n frOm_��to f Pr- ft. Open Hole f�om to ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> \ <br /> Type of Obstructions(Describe) � (�+� <br /> ! <br /> # GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe <br /> FORMATION <br /> 5 If not known,indicate estimated formation log from nearby well or boring. PUMP �/ <br /> j' Type � �'�G 1�- � <br /> t-` �� l T �� �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.trom 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 MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material fV� C' T (?2a"�iC�'i#rom__�� to�� ft. yards� bags <br /> from to ft. yards bags <br /> from to ft. _ yards bags - <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? [j Yes No How many? <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 /> is true to the best of my knowledge. y <br /> T)on Gtoclola ���ell Drillin� Co,. Ir:c. 1t7�1 <br /> Licensee Business Name License or Registration No. <br /> / <br /> o�'/� �` �'�br��., 9' �` / � <br /> QBthlrecYR p�ve S�gr�ture Certified Rep.No. Date �' <br /> _ � <br /> LOCAL COP`1 " 3 416 9 6 ��--�- � <br /> Name of Person Sealing Well or Boring <br /> HE-01434-14 ID#53159 5/13R <br />