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<br /> wELL OR BOaiNG LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �
<br /> Counry Name
<br /> WELL AND BORING SEALING RECORD Minn'egoNa Unique Well No.
<br /> �n�C fn Minnesota S�atutes,Chapter 1031 or W-series No. i _ , ,
<br /> (Leeve blank�i!no�known)
<br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Weil or Boring Constructed �5
<br /> Orono 117 23 11 32-001(? �� Er-lg-gg
<br /> GPS Latitude degrees minutes seconds � �J �
<br /> LOCATION: Depth Betore Sealing ��� ft. Original Depth � / fL •
<br /> Longitude degrees minutes seconds pn�qFER(S) STATIC WATER LEVEL
<br /> Num�e}rLical�rreet Address or Fire Number and Ciry of Well or Boring Location ��ingle Aquifer ❑Multiaquifer
<br /> 14V5 .��.L•���t8 �i�t �d� 0�� ;��WELL/BORING �Measured ❑Estimated
<br /> �� �Water Supply Well ❑Monit.Well �/ I
<br /> Show exact location o�well or boring SkeYch map of well or oring
<br /> in section grid with"X" location,showing pro � ❑Env.Bore Hole ❑Other �� ft. f�below ❑above land surface
<br /> N lines,roads,and build 9ti CASING TYPE(S)
<br /> 1�
<br /> � ��y ` �f �� �Steel ❑ Plastic ❑Tile ❑Other r
<br /> � ,>� 4 � T�
<br /> � �f;
<br /> W — - - -- - — —i— E � � *.) WELLHEAD COMPLETION �--
<br /> r , , � '
<br /> � � � � � �� Outside: ❑Well House Inside: ❑Basement Offset _
<br /> ;
<br /> -;-- ;-- -�— —�'- , i
<br /> � � � �..
<br /> yemile �'_..,..-.� ; � [�iUess Adapter/Unit ❑Well Pit ���
<br /> � � � � _ j .. 'r
<br /> -�-' -i-- -�— —�— � i i . -
<br /> -. ❑Well Pit ❑Buried
<br /> S
<br /> �—�^"�°--�' ��.,� ❑Buried
<br /> � ._
<br /> ppnoFqry nwNER'c Nnnncir.nnnanniv NAME CASING(S)
<br /> 1� fy�—� 1
<br /> ��'�=t` .- �� .�?','f��:,�� � Diamet rt� Depth r Se�in oversize hole? Annular space initially grouted?
<br /> Property owner's mailing address if different fhan well location address indicated above
<br /> � in.from� to�ft. ❑Yes �iio ❑Yes ❑ No ❑ Unknown
<br /> �r
<br /> .. s�a_ �.'..�z�,.i 2 s,a �s�,
<br /> � ,��.�T Sg347 ift.f�om t0 ft. ❑Yes ❑No ❑Yes ❑Na ❑Unknown
<br /> t?f��tl x���� . x
<br /> 9�(,�y���� Ifl.f�om t0 ft. ❑Yes ❑Na ❑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 t0 ft. Open Hole from-��'t0 ZI'' ft.
<br /> OBSTRUCTIONS
<br /> (�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
<br /> Type of Obstructions(Describe) �/�1V'�,�/�Tf"� * / 1��7�
<br /> i
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YBS ❑ NO DeSCfibe
<br /> FORMATION
<br /> If not known,indicate estimated formation log from nearby well or boring PUMP
<br /> gCEIV@Z � 75 TYPe JV�: t"�L�M�
<br /> �emoved ❑ Not Present ❑Other
<br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
<br /> �lo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
<br /> `' 98[i�$t0� 1� Z17 in.from to ft. ❑ Pertorated ❑ 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 bag of bentonite=50 Ibs.)
<br /> /j�/ �- .-���'7/
<br />_ Grouting Material �����/f" "�/from � to._Sr_i.1_ft. yards _�`jp 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�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 is
<br /> true to the best of my knowledge.
<br /> � gt��lr.�€eil �rilli�-C�a., Inr. 7�
<br /> Contractor Business N e �� . License or Regis�tion�
<br /> _ ...._ �,,,% -
<br /> � ;�
<br /> or d Representative Signaturp� + Da e
<br /> Jim Anttmson
<br /> LOCAL COPY H 215 0 3 5 Name o/Person Sealing Well or Boring �
<br /> '. , �
<br /> .�.�.: .,:.,:.:�.a..�� . �-. �,: ...:.,�, , ..,.� �.;.. �_a-..,,�:,,.�-_vG- �v_.,._.�.�_..,�.��., �,:.,v,�-��,`.�..,�-.�:.:��,..�-,..���:-,�..�.�.�:•,..,. _.�.�Ya:q
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