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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring ���^j <br /> WELL OR BORING LOCATION SealingNO. H <br /> County Name WELL AND BORING SEALING RECORD <br /> Minnesota rota Unique Well No. --- -� <br /> Minnesota Statutes, Chapter 1031 or W-series No. <br /> (Leave dank it n W k—) <br /> Township Name Township No,. Range No .Section No. Fraction Ism.-o Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 1 117 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 96 Depth Before Seahrj 1),2 ft Original Depth _�G t ft <br /> Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property k Single Aquifer ❑ Multiaquder <br /> lines,roads,and buildings. <br /> N WELL/BORING Measured El Estimated <br /> ]Water Supply Well [-]Monit.Well <br /> ❑ Env.Bore Hole ❑Other _ It below ❑ above land surface <br /> W --�- -i----- ----------iE { CASING TYPE(S) w <br /> , J <br /> ----------- ---- --�- V ❑Steel 17_Plastic ❑Tile E]Other <br /> Yz mile `��LL <br /> _j__ 4_ _4_ � CASING(S) <br /> Diameter Depth Set in oversize hole'? Annular space initially grouted? <br /> 111l S p�y <br /> lye r m®e— : in.from�__ to 2V�t._. it k Yes ❑No EkYes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in,from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> Hark Rnnll <br /> Property owner's mailing address if different than welt location address indicated abovein.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> Screen from 9,. 4__to2 Q 7 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address If different than property owner's address indicated above Type of Obstructions(Describe) P I; .-a a n d S•t b <br /> Obstructions removed?X12 Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> It not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> o Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> infrom to ry, ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) '�(One bag of cement==94 Ibs.,ohne bag of bentonite=50 lbs.) <br /> Grouting Material PCi Ct I nij- from 292 too_ ft yards bags <br /> from to ft yards bags <br /> from to h, yards bags <br /> _.•___..____.. from to_._ ft, yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused weH-or boring on property? ❑Yes a No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed iiYaccordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> Contractor Business Name ..7— License or Registration Pio. <br /> l <br /> Z t2 . (, Qf <br /> Authorized RepresentativesSiggnat re Lea <br /> yt)¢ Date <br /> cy <br /> anes <br /> LOCAL COPY H 17 7 a 7'7 Name of Person Sealing Well or Boring <br />