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� <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 2 71�2 3 <br /> � WELL OR BORING LOCATION Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> �� Minnesota Statutes,Chapter 103[ or W-series No. <br /> (Leave blank�il no�knownJ <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed �p Date Well or Boring Constructed <br /> �O�O 11lr Z� Zl '/. '/=l�R/< �g'• Z�f LWS <br /> Latitude degrees minutes seconds ��i <br /> GPS Depth Before Sealing ___ ft. Original Depth ft. <br /> LOCATION: Longitude degrees___ minutes seconds <br /> �UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer [�Multiaquifer p/�C/Op <br /> 'j585 $b4Y� �• �� WELL/BORING �Measured []Estimated Date Measured � __-� � <br /> ` �Water-Supply Well []Monit.Well <br /> Show exact location of well or borin � Sketch map of well or boring 6� <br /> in section grid with"X" location,showing properry ❑Env.Bore Hole �]Other _ _._ft. �below �above land surface <br /> N � lines,roads,and buildings. CASING TYPE(S) <br /> '- --'--- —'--- ---`— ---'— <br /> �� �Steel ❑Plastic ��.]Tile I_�Other _ <br /> �� -'--- � —`-- � <br /> r " ; --;--- - ; ---;-- � WELLHEAD COMPLETION <br /> W � � � � E � �'��. <br /> ��� ' � � � -; Outside: ❑Well House ❑At Grade Inside: n Basement Offset � <br /> --;----.-----�-- --:- T <br /> . <br /> �. � , 'h Miie -...� � ❑Buried �l!Well Pit �� <br /> ; � Pitless Adapter/Unit .. <br /> ' --�-- --S : .- ..» <br /> � ❑Well Pit � �Buried <br /> �Other <br /> �1 Mile� . ❑Other <br /> P PERT R'�Ntq7�1E}/C�OMPANY NAME � CASING(S) <br /> ����"`^�~ Diamgter n Depth��C Set in oversize hole? Annular space initially grouted? <br /> Property ownec m� ailinq addr�iflerent than well location address indicated above , jn.from V to � ft. �Yes U No [�Yes �;J No ❑Unknown <br /> 1585 .�hsd &1 <br /> Orono, t� 55331 in.from to n. <br /> ❑Yes ❑No �]Yes ❑No ❑Unknown <br /> in.irom __. to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WEL� L OWf�E�R'SQA E/C tArrNY NAME SCREEN/OPEN HOLE <br /> U�fS�ltl .�c <br /> Well owner's mailing address if different ihan property owners address indicated above SCfeen from �� to 331 ft. Open Hole ffom to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) !_j Debris i �Fill �No Obstruction <br /> Type of Obshuctions(Describe) __ <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 /> Type <br /> �Removed ��_]Not Present n Other _. <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: t <br /> �No Annular Space Exists �_I Annular Space Grouted with Tremie Pipe �!Casing Perforation/Removal <br /> in.from to ft. ❑Perforated n 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 /> Grouting Material��� C�� from O to 331 ft. yards �v bags <br /> from ro R. 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 <br /> is true to the best of my knowledge. <br /> Steveae Drilling i B�r. Svc. iac. 2255 <br /> Licensee Business Name .; ��� License or Registration No. �, <br /> r <br /> � <br /> , � 555 8/18l/S k <br />' ' Certilied Representative Signature Certified Rep.No. Date <br />_ �cc��;;o-�; H 271423 ?ii Stevens <br /> Name ol Person Sealing Well or Boring <br /> iE-01434-10 IC#140-0423 5/ma <br /> i.._....__ .._.._. . ... . . ... . . , . . ,.. _..,... ...._...�.::.a,.�:......u.,.. . .. . ... <br />