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MINNESOTA DEPARTMENT OP HEALTH Minnesota Well and Boring 1 r"'��� � („' <br /> > WELL OR BORING LOCATION Sealing No. H .,J �,j,,,I `) <br /> ^ County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Cha ter 1037 or W-series No. <br /> �il[le'��.Ll P iwa�a oia�x�i�o�k�ow�� <br /> Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono lI7 2 OS r•NF'� ,� � ` �('+,J ( <br /> . <br /> GPS Latitude degrees minutes _ seconds Depth Betore Sealing� ft. Original Depth __ fl. <br /> �'t LOCATION: Longitude__ degrees minutes seconds �FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ��ngle Aquiter ❑Multiaquifer �} � /��� <br /> 495 thcfarr1 R�, CIrOI� y�✓[€LUBORING �Measured ❑Estimated Date Measured.�7��.� �X! <br /> �7 Water-Supply Well ����MoniL Well � <br /> Show exact location of well or boring Sketch map of well or b ring i �/ <br /> - in section grid with"X" location,showing prope ty ��Env.Bore Hole � �Other____ �r _ft. �below �]above land surface <br /> N lines,roads,and buildin s`` CASING TYPE(S) <br /> �� --'--- —— `- ---'— . ��. <br /> � ; i , f �� 1 steei ❑Piast�o Cl T�ie -I o�ne� —___ _ _ <br /> �\ <br /> � "''- � ' ' -�' '''-- � WELLHEAD COMPLETION <br /> . W ; ; ; ; ET � <br /> _� ;_ _ _�___ r }, Outside: ❑Well House []At Grade Inside: ❑Basement Offset � <br /> 'h Miie ' ❑Buried ❑Well Pit ` <br /> � . :\ �Pitless Adapter/Unit � <br /> ❑Buried : <br /> S /^�, ❑Well Pit <br /> ❑Other <br /> �1 Mile� ' ❑Othef <br /> PR E+RTY OWP�NER'S MPANY NAME CASING(S) <br /> �`��'41�`��"�� Diam ter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different ihan well location address indicated above �f <br /> r ' <br /> �_in.trom Q to� � ft. n Yes �No !.]Yes [_j No ❑Unknown _ <br /> 7407 Tdayzata BZvd _ ° <br /> .7t Wli�$ �$��� M�3 55426 in.fram to ft. �]Yes '���_�No ��LJ Yes L�No �Unknown <br /> __in.trom to ft. ❑Yes ❑No [.J Yes L I No j]Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � � <br /> Well owner's mailing address if different than property owner's address indicated above Screen from_�� to f�� ft. Open Hole from to _ft. <br /> �-�, �� �. � t_='1� �t��t�- "' i�)�...i � OBSTRUCTIONS <br /> �Rods/Drop Pipe �]Check Valve(s) �]Debris [�Fill [�No Obstruction <br /> 3 Type of Obstructians(Describe), /n/N�� /=� 4' �U/1')(� <br /> J'-- <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 /> l� r TYP� ��JQ� M - — <br /> ? , �-- <br /> i - E� � � �`-'�� �,Removed �;Not Present r]Other ... __ <br /> ;��J METHOD 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 [i Removed <br /> in.from,__ to ft. ❑Perforated ❑Removed <br /> Type of Pertorator_ <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> � �a+ � i <br /> ? GroutingMaterial/V�I�rr �L��+� from U to�� ft. yards ��- bags <br /> from to ft. yards _ bags <br /> from to ft. yardg _ bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIPFICULTIES IN SEALING Other unsealed and unused well or boring on property? I 1 Yes �No 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 /> Ibn Stalola ��ell Dr�.11in� Co.� Inc. 1691 _ <br /> Licensee Bus�nes Nr+e { ' /. � License or Registration No. <br /> ...-'��"/i `���� ��/ -„- . /�%' <br /> / / `/ <br /> _C,SRR'i Representative Signatuie - � Certified Rep.No. Date <br /> c <br /> ; � <br /> ���� " 3 0 9 6 � 5 ,.__r___. _�-� � _. _, ..v; <br /> -_ - - - � - <br /> � Name ol Person Sealing Well or Boring � <br /> HE-01434-13 IC#140-0423 . � 5n2R <br /> � <br />