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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 9 9 O 7 <br /> Sealin <br /> County Name <br /> WELL AND BORING SEALING RECORD Minneso aoUnique Well No. `j <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township r Township No. Range No. Section No. Fraction(sm.—a Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 - ig 1.04 NB Si AU& I I <br /> GPS Latitude degrees minutes seconds Depth Before Sealing •1 ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds <br /> AQUIFERS) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ��,,// .�,t�r.f tor'WELL/BORING �/�•Measured ❑Estimated Date Measured �.�+/.r 4/z` <br /> 840 Old Crystal Bay . . S, Orono Y 'Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring �`, R'ketch map of well oring ft, below <br /> in section grid with"X." 7 +M ation,showi ❑Env.Bore Hole ❑Other ❑above land surface <br /> es,roads,and buildings <br /> N }{ CASING TYPE(S) <br /> Steel E Plastic ❑Tile ❑Other <br /> .....1______—___$------i_-- 1 \ , WELLHEAD COMPLETION <br /> w E <br /> ___I___.__}___--4 <br /> ______I___ T Outside: ❑Well House ❑At Grade Inside: Basement Offset <br /> 1mile ❑Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> ❑Buried <br /> S / ❑Well Pit <br /> T ( ❑Other <br /> —1 Mile----1 ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> tharlI Diameter . Depth t• • Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address it different than well location address indicated above �� <br /> in.from to © ft. ❑Yes K"No ❑Yes ❑No ❑Unknown <br /> 15050 23rd Ave N in.from to ft. ❑Yes ❑No ❑Yes LI No ❑Unknown <br /> Plymouth, MN 55447 <br /> in.from to_ ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE , <br /> Well owner's mailing address if different than property owner's address indicated above Screen from 9�. to �� , ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑DebrisQ(ill ❑No Obstruction <br /> Type of Obstructions(Describe) am, AJY I'��ApAhreg,. /� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? [ es ❑No Describe CIU�e� Allen 4e,�O <br /> FORMATION <br /> If not nonindicate estimated formation log from nearby well or boring. PUMP <br /> Type <br /> ❑Removed ( (lot Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> )11to Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from ' to fti 30 Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement.94 lbs.,one bag ofbentonite.50 lbs.) <br /> • <br /> Grouting Material 7/'/ tt..CJ.1K—�! from GO to •T ft. yards 2 bags <br /> °'It from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BSiR J i <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING It <br /> Other unsealed and unused well fir bring o property? [_J Yes Xlo How many? <br /> LICENSED OR REGISTERED CalTR.'l3�CTO C RTIFICATION <br /> This well or boring was sealed in accdn i\l$Jrrnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. VV <br /> 711 <br /> Don Stable Wel + `libing Co. Inc. 1691 <br /> Licensee Busi - N. e License or Registration No. <br /> :;;.,:e 4?-- /— 1 1 <br /> Ce+ re•resentative','.� <br /> � a ure Certified Rep.No. Date <br /> 0.")......* <br /> LOCAL COPY H 299007 <br /> Name of Person Sealing Well or Boring <br /> HE-01434-12 IC#140-0423 9/09R <br />