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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' `� �P�b f �
County Name
WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. .-t
Nenne�in Minnesota Statutes,Chapter 1031 °eaW series Na
Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Consiructed
Orora 117 23 07 t�'�t S� S�: �_ � �_ 1 y
GPS Latitude degrees minutes seconds Depth Before Sealing_�5,;7 ft. Original Depth ft.
LOCATION: Longitude degrees__ minutes seconds
AQUIFER(S) STATIC WATER LEVEL
� Numerical Street Address or Fire Number and City ot Well or Boring Location �I Single Aquifer �_�Multiaquifer ! "� ) F j
417� trvtt[i JII��Q �}r �J�O� 55364 WELVBORING �Measured �_]Estimated Date Measured�! /' f ._,..' _
�Water-Supply Well ❑MoniL Well
; Show exact location of well or boring Sketch map ot well or boring - �/�j �
� in section grid with"X:' ation,-sh ing pro n Env.Bore Hole �.',_,l Other ___ �tt. �below �J
��� �,�� _ above land surface
N r d n Idi s. CASING TYPE(S)
' --'-- —'-- --`----'— �\
_ [�Steel ❑Plastic ❑Tile �]Other _ _
_____ ______ ___ __ ____ �� WELLHEAD COMPLETION
W ET
Outside: ❑Well House [_�At Grade Inside: ❑Basement Offset
.., , , . , Mile itless A p r/Unrt ❑Buried �Well Pit
�� �P da te i
------ ---------�-- ---:- 1 �
❑Well Pit I]Buried
S
❑Other
��Mile� ❑Other __
�
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
�r Dia ter Depth Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than weli location address indicated a6ove � jn.from 0 to �� ft. ❑Yes �]No ❑Yes ❑No ]Unknown
in.from ta ft. ❑Yes r]No ❑Yes . ❑No �_]Unknown
_in.from to ____ft. ❑Yes [.J No ❑Yes ❑No �I Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
Well owner's mailing address if different than property owner's address indicated above SCreen from_��t0�+.��ft. Open Hole ffom ___to ft.
OBSTRUCTIONS
,�J Rods/Drop Pipe ��Check Valve(s) �]Debris ; ;Fill ',J No Obstruction
Type of Obstructions(Describe) �,l' �+ �i V c' -
� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Q;Yes [__]No Describe
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring. r
l � A.✓ � � TYPe-.�/��
I,�Removed ❑Not PreseM ❑Other_
- � METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
2��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.)
�� Grouting Material �`r! � I^ --�-{�' from n4. to +✓-� ft. yards � bags ���
1
; from to tt. yards bags
from __ tq_ ft. yards bags
OTHER WEILS AND BORINGS �
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �__J Yes �No How many?
RECEIV�D LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
is true to the best of my knowledge.
F�S 4 -- �Q�3 Ikin Stod�la T�eII nrillin� Co., inc. 16�i
L�censee Business Name J�-�- . License or Registration No.
CITY OF ORONO ' �._
,, y ,��� �� t /-jt� /�
% `� .
��rtiHed Representahve S�gnatur'e Certilied Rep.No. Date
...��' -> f/'".
" 3 0 ��4° �.�ti.����,�
�ocn�.�o�v ,��._,...�....
� Name of Person Sealing Well or Bo�ing
HE-07434-13 IC#140-0423 5n2R