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/j WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 5 2 2 <br /> County Name WELL AND BORING SEALING RECORD Minneso aSealinoUnique Well No. 6`{ <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> is on rta oii111 <br /> Township Name Township No. Range No. Section No. Fraction(sm. Ig.) Date Sealed Date Well or Boring Constructed <br /> 0rouo 0 F.1i7 c3 Lu ''.—.. /(—.) ,/ <br /> /26 /7 <br /> GPS LOCATION— decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 22/ ft. Original Depth ft. <br /> Latitude Longitude <br /> AOUIFER(S)' STATIC WATER LEVEL ' <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> WELL/BORING Measured Date MeasuredSR1 ffl& 'r El Estimated <br /> '` . '" r* . rz s )4Water-Supply Well ❑Monit.Well rr <br /> Show exact location of well or boring !4., Sketch map of well or boringn <br /> in section grid with"X.' 4 1 location,showing property El Env.Bore Hole EI Other 57 ft. below ❑above land surface <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> QJ <br /> yil,y %Steel ❑Plastic El Tile ❑Other `{ �`Ep� <br /> V <br /> ---i- - --'------t---- - �',. 1 WELLHEAD COMPLETION <br /> W E <br /> T Outside: Pitless Adapter/Unit 10 At Grade Inside: EI Basement Offset JAN <br /> 201 <br /> h Mile �' II] Pit ❑Buried ❑Well House <br /> r-- I ` U ❑Well Pit <br /> 1 by El Other ❑Buried <br /> CITY OF ORONO <br /> 5 <br /> 1 Mile (�J ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> a Diametar , Depth Set in oversize hole? Annular space initially grouted? <br /> tismaiingad ieli i3$til is u�;rTZi <br /> Property owner's mailing ad ress i di Brent than wenIota n address indicate above in.from2IL to ! ft. ❑Yes gNo ❑Yes ❑No ❑Unknown <br /> 1611U ''iinaetonka blvd. <br /> t ayzata, kA . <br /> 551 in.from to ft. ❑Yes ❑No El Yes ❑No LI Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r <br /> Well owner's mailing address if different than property owner's address indicated above Screen from 2�? to ftI . Open HOIe from t0 ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑De�briss El Fill El No Obstruction <br /> Type of Obstructions(Describe) <br /> ....//V4f/L.1 /�? - (/LJ/�/ <br /> GEOLOGICAL MATERIALI COLOR HARDNESS OR <br /> FORMATION FROM TO Obstructions removed? XYes ElNo Describe <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> El Not Present Present,Removed Prior to Sealing LiOther <br /> 7 c)rC;F 1 iz+ Type 5U ('')( l�U(Yi() <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> as g 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? El Yes , No TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material A/e ` Ic_"j1.l9from C/ tq_ZEZ ft. yards /8 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 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 /> is true to the best of my knowledge. <br /> LJ.i S i'ubULA WELL DkILLIAG 0-.). , 1si9. 1691 <br /> Licensee Business NameLicense or Registration No. <br /> J5o 1f�. ' I '/ <br /> rt.led p sentative Signature Certified Rep.No. Date <br /> LOCAL COPY H 3 5 2 26 /� <br /> `tName of Person Sealing Well or Boring <br /> HE-01434-15 ID#53159 8n6R <br />