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Minnesota Well and Boring <br /> ,a WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 5 5 0 9 8 <br /> �o��ty Name � WELL AND BORING SEALING RECORD Mmnesota u�iq�e No. <br /> j�j����, Minnesota Sta�utes.Chapter 103/ or W-series No. <br /> i7C",j3►��Zn ILeave blank if nol known) <br /> Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br /> �� }�� �.S �� 33�-�C�13 �ia ��t,.:� � ���- .. �����t.� or Boring Consiructed <br /> Numerical Street Address or Rre Number and City of Well or Boring Location { (� <br /> 625 S`��rir� Hili Rcx�c3 Orono, �"Y7• 3�391 Depth Before Sealing � " `�' fl Onginal Oepth � �0 1�. <br /> Show exact bcatron of well or boring Sketch map of well or boring Static Water Level ccurate <br /> in sechon grid with��X��. location,showing propecly lines. - <br /> N ._ �adsi�d t4ai��gs. ❑Approximate <br /> I I I I �' �~ �_Vi' <br /> I I I I ��� <br /> � Single Aquiter ❑Multiaqu0er ft. � below above land sur(ace <br /> i i i i <br /> _i_ _�_ _i_ _i_ CASING TYPE <br /> W � i � � E a �1 <br /> i i i i T �'�` �ya. <br /> -r -7- -r- -r <br /> i i i i �,.�e teel ❑Plastic ❑Tile ❑Other <br /> _i i i i_ � (� � t (} <br /> i_ _ i_ _i_ _ <br /> S Screen from ��`�"� to � fl. Open Hole from to it. <br /> �—i mi�e—►I OBSTRUCTION/DEBRIS/FILL <br /> Obsiruction ❑Debris ❑Fill <br /> PROPERTY OWNER'S NAME �.. ,._., <br /> Lsl�; �;hI1 >�- <br /> Type of debris/obs[ruction ''`�``l� r �-'� ;''E-�' �� ��.� .�'�"�. }"� <br /> Mailing Address rf different ihan property address indicated above. + <br />� Obstruction/Debris/Fill removed? Yes ❑No <br /> ` PUMP <br /> Lp,Removed ❑Not Present ❑ Other ����.4 �y � V 4 � � ` �_ r�,. � `4 <br /> t <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Se!in oversize hole7 Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> �in.from {" to � f��� k. ❑Yes � ❑Yes ❑No ❑Unknown <br /> � <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> M THOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑PeAorated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> g ' �� y .� bags <br /> i - <br /> Groutin material g����+.��� ����``�hom to � ' `-� ft. ards f ti <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to fl. yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes No <br /> LICENSED OR REGISTEHED CONTRACTOR CERTIFI�ATION <br /> �� �'�' � � `� This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to ihe best of my knowledge. <br /> S E P 2 i 2994 � ��� w�. �ussr�c cu., �Nc. �7�7z <br /> r Conhactor Business ame License oi Registration No. <br /> \.-�- . .,., . {'.',. . .. ,, . .,. .��� . <br /> ., . � ..____ i �-�-� . <br /> �� �� <br /> ut zed Representative Signatvre Date <br /> �ocn��o�v H 5 5 0 9 8 � �e <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-01 <br />