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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring o. H 108150 <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnSeallesotta Unique No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> TLnrriapin (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-�-Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 <br /> Numerical Street Addressor Fire Number and City of Well or Boring Location / <br /> +� / <br /> 7 0'30 •r� Rd, Orono <br /> Depth Before Sealing / ft. Original Depth -12e- 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 propertyIngle Aquifer ❑ Multiaquifer <br /> lines,roads,and bultMngs-'; <br /> WELL/BORINGvteasured ❑ Estimated <br /> \\ � _yj• � Water Supply Well ❑Mont.Well � <br /> ❑ Env.Bore Hole ❑Other ft. >ielow ❑ above land surface <br /> f <br /> W -� -� ; -� E I CASING TYPE(S) <br /> -�- -i-- --i-- --�- (Steel ❑ Plastic ❑Tile ❑ Other <br /> mile 7 <br /> CASING <br /> _ Diameter Depth / Set in oversize hole? Annualar space initially grouted? <br /> "'in. rj <br /> 1 mile s r{.�1 from� to J_j_r:� ft. ❑ Yes �J0 ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from _ to ft. ❑ Yes r❑_No ❑ Yes ❑ No ❑ Unknown <br /> Keith T <br /> Ratwrs Associates, <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> 10340 Vii ry Dr,,' Ste 110 <br /> SCREEN/OPEN HOLE <br /> itY ' <br /> ffim Prairie, 55M4 Screen from_1/ 6 o_�� ft. Open Hole from to ft. <br /> OBSTRUCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill <br /> Obstruction/Debris/Fill removed? Xes ❑ No <br /> PUMP y��'r/y <br /> Type �� // //— <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FRORemoved El Not Present El Other <br /> FORMATION M TO <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> tf � <br /> No Annular Space Exits <br /> �. r ❑ Annular space grouted with tremie pipe <br /> / ❑ 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) <br /> Grouting Material ya,/6-�r^ -_ to ft. yards �/� bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes o <br /> LICENSED OR REGISTERED CONTRACTOR CERTIF CA ION <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 /> ContracTo ins a la Well • +License or Registrati 72 <br /> y� <br /> A on �entatN Signature Date <br /> Name of Person Sealing Well or Boring <br /> LOCAL COPY H 108150 <br /> HE-01434-02 10/95R <br />