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WELL OR BORING LOCATION" <br />MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br />Sealing No. <br />WELL AND BORING SEALING RECORD Minnesota unique Well ND: <br />Minnesota Statutes, chapter 1037 or W-series No. <br />(emeaaN if .1 wmm> <br />H 381514 <br />County Name <br />Hermep .n <br />Township Name <br />Orono <br />Township No. <br />1117 <br />Range No. <br />23 <br />Section No. <br />109 <br />Fraction (sm. -r Ig.) <br />,SS /° SH <br />Date Sealed <br />Date Well or Boring Constructed <br />GPS LOCATION - decimal degrees (to four decimal places) <br />Latitude Longitude <br />Depth at Time of Sealing_ _ ft. <br />AQUIFER(S) <br />Single Aquifer ❑ Multtaquifer <br />Original Depth ft. <br />STATIC WATER LEVEL <br />Measured Date Measured ) ❑ Estimated <br />Numerical Street Addressor Fire Number and City of Well or Boring Location <br />WELL/BORING <br />Show exact IOCabOn o we or bor ng ap.ei wel or boring?` <br />in section grid°with "X:' location, showing operty <br />lines, roa , and b iidings. <br />N y <br />9 Water-Supply Well ❑ Env. Well <br />El Tempi Boring El Other. <br />_) <br />ft. [below Elabove land surface <br />CASINGTYPE(S) <br />, 1. <br />Steel ❑Plastic ❑Tile' ❑ Other ' <br />WELLHEAD COMPLETION <br />Outside: / Pitless AdapterNnit ❑ At Grade Inside: ❑ Basement Offset <br />/❑_Well <br />?h Mile <br />## <br />- -s <br />Pit ❑ Buried ❑ Well House <br />El Well Pit <br />El Other <br />❑ Buried <br />I 1 Mile <br />t.� s <br />El Other <br />For-temporary borings, provide additional location 14dCASING(S) <br />information, a site sketch, and geology on a separate page. <br />Di er Depth _ Set in oversize hole? Annular space initially grouted? <br />in, from -) toft. ❑ Yes rXo '' El Yds, ` [:1 No El Unknown <br />in. from to ft. El Yes ❑ No ❑ Yes ❑ No ❑Unknown <br />PROPERTY OWNER'S NAME/COMPANY NAMEy�� <br />O & - Z as <br />Property owner's mailing address if different than well location address indicated above <br />18212 om Blvid <br />Deepbavenj M 55391 <br />in. from to ft. ElYes ❑ No ElYes ❑ No [:1Unknown' <br />SCREEWOPEN HOLE <br />Screen from to IIIft. Open Hole from to ft. <br />WELL OWNER'S NAME/COMPANY <br />'NASsME o <br />B SJ & a �[1ie Heffes <br />,,,,O-BSTRUCTIONS <br />pO Rods/Drop Pipe El Check Valve(s) Debris El Fill El No Obstruction <br />rType <br />Well owners mailing address if different than property owners address indicated.above <br />f❑j <br />of Obstructions (Describe) <br />Obstructions removed? gYes ❑ No Describe <br />I <br />PUMP <br />❑ Not Present {Present, Removed Prior to,Sealing ❑ Other <br />Type, ,-- •y y.` , <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS ORFORMATION <br />FROM <br />TO <br />If not known,' indicate estimated <br />formation log from nearby well or boring. <br />j <br />y r"METHOD <br />i <br />USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />No Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe + ❑ Casing Perforation/ReImovai <br />Casing Diameter <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? ❑ Yeso TN# <br />GROUTING MATERIAL(S) <br />Grouting Material 'y r civ ° frofi = 40 yards f bags <br />from to ft, yards bags <br />from to : ft, yards bags <br />OTHER WELLS AND BORINGS '- <br />Other unsealed and unused well or boring on property? ❑ Yes XNo 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 />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />is true to the best of my knowledge. <br />DON SM' W DR1U. # ; =Ct 1.69.1 <br />Licensee Business N e License or Registration No. <br />y <br />ili F7e/iresentalive Signe `` Cethfied Rep No " Date ` <br />LOCAL COPY <br />H <br />3815 4 <br />f <br />Name of Person Sealing Well or Boring <br />HE -01434-17' ID# 53159 <br />it. <br />