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.. <br /> Minnesota Well and Boring 33414 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota unique No. <br /> — <br /> Hennepi n Minnesota Statutes,Chapter 103/ or W-series No. <br /> (Leave blank.1 not-own) <br /> Township Name Township No. Range No. Section No. Fraction Ism. �Ig.) Date Sealed Approximate Date Well <br /> Orono 118N 23M 31 1 SE,4 SEtAV. 11/10/93 or Boring Constructed <br /> Numerical Street Address or Fire Number and City of Well or Boring Location p <br /> 425 Turnham Road Depth Before Sealing 198 ft Original Depth it <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level El Accurate <br /> in section grid with'X location.showing property lines. <br /> N roads,and buildings. r.]Approximate <br /> Single Aquifer ❑Multiaquifer 1777 ft, below above land surface <br /> _ CASING TYPE <br /> W E <br /> T <br /> KI Steel El Plastic El Tile El Other <br /> i,mile <br /> S Screen from to fl. Open Hole from to ft. <br /> OBSTRUCTION/DEBRIS/FILL <br /> ❑Obstruction ❑Debris ❑Fill <br /> PROPERTY OWNER'S NAME <br /> William Stempel <br /> Type of debris/obstruction 'e <br /> Mailing Address ifdifferent than property address indicated above. <br /> Obstruction/Debris/Fill removed? ❑Yes 11 No <br /> 425 Turnham Road PUMP <br /> Maple Plain, MN 55359 <br /> Removed ❑Not Present ❑ Other <br /> 41 HARDNESS OF CASING <br /> GEOLOGICAL MATERIAL COLOR FORMATION FROM TO <br /> - Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> 4 in from to — ft ❑Yes ❑No ❑Yes ❑No ®Unknown <br /> " in.from to — ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to — ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACI=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 /> infrom to fl. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> Grouting material neat cement — from 0 to 198 ft. yards 17 bags <br /> from to ft. yards bags <br /> }.; REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft, yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? 1iYes ❑No <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 is <br /> true to the best of my knowledge. �Q- <br /> W -11 <br /> Contractor usiness Name ktf--1--1--f--F--' --- - License o e istration No. <br /> 11/15/93 <br /> Authorized Representative Signature Date <br /> LOCAL COPY Dan Maas <br /> H 33414Name o/Person Sealing Well or Boring <br /> HE-01434-01 <br />