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MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring �����(� <br /> WELL OR BORING LOCATION Se811f19 NO. i H— p <br /> Counry Name WELL AND BORING SEALING RECORD Mi��esota u�iq�e we��rvo. � -- <br /> Minnesota Statu�es.Chapter 103/ or W-series No. <br /> Henrie i n h.�.a.�x�k^�� — <br /> Township Name Township No. Range No Section No. Fracuon�sm.-s Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 1 l7 23 44 . ,. f"� ��� �� <br /> Numerical Street Address o�Fire Number and Ciry ol Well or Bonng Locauon J <br /> 2685 ��i�� �0$� V=��a> ��5�� Qepth Before Seal�ng_�__ft Ongmal Depth l 11t� R <br /> Show exact locahon ol w�ell or boring Sketch map ol well or boring ApUIFER(S) STATIC WATER LEVEL <br /> in section gnd wrth"X". .,Joca�ion, showing property �ingle Aywfer � MulUaquiter <br /> .lines,roads,and bwldings. <br /> N � WELUBORING Measured ❑ Esumated <br /> � � � � ,r�-5�- �'Water Supply Well ❑Mornt.Well <br /> � _�__ � � � <br /> --r' --r- --�-- #f . <br /> --, F�� � t��� ❑ Env Bore Hole ❑Other _ _ ft [�below ❑ above land surface <br /> . �+,�� <br /> W —i-- -i-- -i-- —;-- E CASING TVPE(S) . <br /> � � � � <br /> � � � � <br /> -�-- - -'- —' � [� <br /> --- �' �-' teel � Plastic �Tile � Other � <br /> }zmile I <br /> —�- -�-- -�— --�-- � CASING(S) <br /> � Diameter Depth Set in oversize hole9 Annular sp2ce initially grouted? <br /> L� S �J� ,7 "" <br /> �tr—�mae--a�e " ��� �� � m.from__.�_ to �1� tt. ❑ Yes ❑No ❑ Ves ❑No ❑ Unknown <br /> I I <br /> PFOPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ �es ❑No ❑ Unknown <br /> T Bren Ho�e� <br /> Property owner's mailinq adtlress B ditterent ihan well location address indicated above. in.from to fl. ❑ Ves ❑ No ❑ Yes ❑No ❑ Unknown <br /> '���� T�r��� �Q�� SCREEWOPENHOLE <br /> Indepe�dence, ��• Screen from � � to� fl Open Hole from to R. <br /> ��3�$ ossraucnoNs <br /> WELL OWNER'S NAME <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's meiling aAOress if diHerent than property owner's atltlress mdicated above. Type ot Obsiructions(Describe) +,�,,,,� �>....? w�"i.s���F�"',�"� <br /> • Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type „�y :l �� <br /> GEOLO(i1CAL MATERIAI COLOR HARDNESS OF FpOM TO emoved ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formatbn log from nearby well or bonng METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> f�No Annular Space Exists <br /> � ❑Annular space grouted with tremie pipe <br /> ❑Casing Pertoratlon/Removal <br /> in.from to R. ❑ PeAorated ❑ Removed <br /> in.irom to ft. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ othe� <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 Ibs.) <br /> Grouting Matenal!��`���'`�� t �t����„r�+m to tt. yards � ba <br /> � <br /> from to 8. yards bags <br /> from to ft. yards bags <br /> hom to__ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEAIING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes ❑No How many? <br /> LICENSEO OR HEGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealetl in accordance with Minnesola Rules,Chapter 4725. The information contained in this report is <br /> � true to ihe best of my knowledge. <br /> DON STODO�.A 'WSLL DIi�LLING C4., �xe. z���2 <br /> Confracfor Business Nam License a Regisfrefion Fo. <br /> i <br /> , <br /> ' /- /,._„t ;,,�j "� <br /> f � J <br /> on R senta rve Dete <br /> ' .._�•—•.--�,.-.... -�...,,..,,��...:?.r i�.� � ���J <br /> i - H 1�319 6 Name ol Person Sealing Well oi Bonng - <br />