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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Borirtg H 2 g 6 3 0 5 <br /> County Name <br /> WELL AND BORING SEALING RECORD Menn�e9oNa Unique Well No. <br /> �pin Minnesota Statutes,Chapter 1037 or W-series No. <br /> (LEdve bldnk il no�known) <br /> Township Name Township No. Range No. Sec[ion No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed <br /> E?rono 117 23 QZ S'� � 9W / `/v,v,� <br /> . <br /> GPS Latitude _ degrees minutes seconds Depth Before Sealing �� ft. Original Depth _ ft. � <br /> LOCATION: Longitude degrees minutes seconds A�UIFER(S) STATIC WATER LEVE <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer � ,/t A'� <br /> 12S5 Dicloec�oc� St, 0� WELL/BORING �Measured �_J Estir�ated Date Measured �►`�� iy�r <br /> �Water-Suppiy Well ❑Monit.Well � � <br /> Show exact location of well or boring Sketch map of well or boring �� <br /> in section grid with"X." I ation,showing proper4� � .�Env.Bore Hole ❑Other ,_._ ft. �below ❑above land surface <br /> N ,���.l��ads�n i ings}...i CASINGTYPE(S) <br /> 'GY' <br /> r <br /> --'-- --'--- ---'-----'-- � <br /> �.Steel �Plastic �J Tile ❑Other_ ___ <br /> --'--- --�--- ---`-- ---`-- WELLHEAD COMPLETION <br /> W : : : : ET � <br /> � � _;_____;_ � Outside: [:Well House �]At Grade Inside: ❑Basement Offset <br /> 'h Mile Buried ❑Well Pit <br /> --�-- -T----�-- ---�-- less A p dUnit � d <br /> 1 �pit da te <br /> ❑Well Pit ��Burie <br /> S ❑Other <br /> �-1 Mile—� ❑Other <br /> PR�E�Tx QWNE�S 1�4ME/COMPANY NAME CASING(S) � <br /> �� �K> '� Diame er r Depth � Set in oversiz�hole? Annular space initially grouted? <br /> Property owner's mailing address if diflerent than well location address indicated above ���rin.from Q to �� ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> 1I401 �ey Rd 3 <br /> aeupl�.L�� I� 553Ei3 in.from [o 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 s � <br /> Well owner's mailing address if different ihan property owner's address indicated above SCreen from / r t0�ft. Open Hole frOm_�to ft. <br /> OBSTRUCTIONS <br /> ;�Rods/Drop Pipe ❑Check Valve(s) I ��.Debris [Fill ',_,No Obstruction <br /> Type of Obstructions(Describe) �Rl/�_� �� 4 �n <br /> T <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe � <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> r Type_�V � L�(� � <br />� .�'-�` � �� Removed ❑Not Pr sent ❑Other <br /> rf �HOD 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/Removal <br /> in.from to ft. ❑Perforated ��Removed <br /> in.from to ft. ❑Perforated �,Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one b8g of bentonite=50 Ibs.) <br /> I r <br /> GroutingMaterial�L/QT��L trom � 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? ❑Yes o i How many? <br /> RECEiVED 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 knawledge. � <br /> JUL -5 2011 <br /> Dan Stvdola tie22 illfr� Co., �nc. i591 <br /> CITI(OF ORONO licensee Business Na e License or Registration No. <br /> �.l��� y� £f� � // <br /> � <br /> r' presentative Sign ur � Certil'd Rep.No. Date <br /> LOCAL COPY H ,--- _�Y�/•1tS Y� <br /> 2 9 6 3 0 5 Name of Person Sealing Well or Boring <br /> HE-01434-12 IC#140-0423 �� s/osR <br /> ��'I . _ I ..�,,.... � . <br />