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Minnesota Well and Boring 28910 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> itenwpin Minnesota Statutes.Chapter 103/ or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm. I Ig.) Date Sealed Approximate Date Well <br /> Orono 117N 23W 21 W NW„NW„ 6/793 or Boring Constructed <br /> Numerical Street Address <br /> oorr'Fire <br /> {,Number and City of Well or Boring Location <br /> 2540 Old Beach Road Depth Before Sealing 225 It Original Depth ft. <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level Accurate <br /> in section grid with"X'. location,showing property lines. <br /> N roads,and buildings. ❑Approximate <br /> 85 X <br /> LTSingle Aquifer ❑Multiaquifer ft - below above land surface <br /> I 1 I I <br /> CASING TYPE <br /> W E <br /> T <br /> i I I I Leel El Plastic El Tile El Other <br /> mile <br /> S Screen from to ft. Open Hole from to ft. <br /> OBSTRUCTION/DEBRIS/FILL <br /> ❑Obstruction ❑Debris ❑Fill <br /> PRtU&RT IlaWl NAM <br /> Mailing Address it Type of debris/obstruction <br /> different than property address indicated above. �- - <br /> 2540 Old Beach Road Obstruction/Debris/Fill removed? ❑Yes ❑No <br /> Orono, M 55 1 PUMP <br /> (j Removed ❑Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> 3 in.from to ff. ❑Yes ❑No ❑Yes ❑No EgUnknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 9 No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> t <br /> i in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> L_ <br /> ❑Other <br /> GROUTING MATERIAL �,.,,,�♦ <br /> Grouting material Neat CErent from 225 to _0 ft. yards 7 bags <br /> from to ft, yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on properly? Yes ❑No in use <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 is <br /> true to the best of my knowledge. <br /> 27194 <br /> C-A,a-o-r-u-in-e�same License or Registration No. <br /> 5/7/93 <br /> Authorized Representative Signature Dat <br /> Thows Stelens 6/7/93 <br /> LOCAL COPY I„+ 2 Q 91 O <br /> L Q Name o/Person Sealing Well or Boring <br /> HE-01434-01 <br />