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� <br /> v�(EL4 OR.�ORMIG LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 0 213 2 <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. <br /> County Name --- <br /> � Aennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave hlank�ii no�known) <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 17 4;.Otl.�l ,. � O!/ Z <br /> GPS Latitude degrees minutes seconds � � � <br /> LQCATION: Depth Before Sealing �� ft. Original Depth � ft. <br /> Longitude degrees minutes seconds qQU1FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 192Q Shadywood Rd, OCOIZO WELUBORING �(Measured ❑ Estimated <br /> `�Water Supply Well ❑Monit Well <br /> Show exact location of well or boring (� Sketch map of well or boring � <br /> in section grid with"X° �{_ location,showing property ❑ Env.Bore Hole ❑Other _,��_ _ft. �elow ❑above land surface <br /> �� lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> ' �(,V, I]CSteel ❑ Piastic ❑Tile ❑Other <br /> T <br /> W -- - -- - — -- -- E � i <br /> WELLHEAD COMPLETION <br /> � � � � � Outside: ❑Well House Inside: ❑Basement Offset �� <br /> -�— -�-- -;-- --�-- �- -� <br /> � � � � ` �.� <br /> y�mi�e '�. � �itessAdapter/Unit ❑Well Pit <br /> � � � � �_, <br /> -�-- -i— -�-- --i— I <br /> 1 � ❑Well Pit ❑Buried <br /> S <br /> �i mee—�. �'— . <br /> ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � � Diameter � Depth / Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above � �/� <br /> � in.from� to��lft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> I133 Thorn St <br /> .7 C Pa�1� I�N 5 5106 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑ Unknown - <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> I / <br /> Well owners mailing address if different than properry owner's address indicated above Screen from�t0�ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS - <br /> (�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe)�itliU����r� ¢ �!J/�P <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 2S ❑ NO DOSCrlb2 <br /> FORMATION - <br /> If not known,indicate estimated formation log from nearby well or boring PUMP ' . <br /> TYPe S�J PC1C�-� <br /> �Removed ❑ 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 /> in.from to ft. ❑ Perforated ❑ 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 /> i <br /> Grouting Material � m—�_to—��ft. yards � 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 REGISTEflED 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 /> . .�_ , � ��.`�i Dnt� Stodala Wcs11 Dr�17 i n�� TnC_ 27I72 <br /> I /� Contractor Business Name `^e� License or Regislration No. <br /> i�^,ol N [_ � �Ppl!7 f/ <br /> � �! ,/v� O Z <br /> � .. ._ _ ' ' <br /> ��';� �y� ��„����a A t ive ignatur€�'� ��� �� Date <br /> ..,`\\ ;�--�-, �� <br /> LOCAL COPY H 2 O 2 1 3 2 Name of Person Sealing or Boring � <br />