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MINNESOTA DEPARTMENT OF HEALTH M�nnesota Well and Bonng `L� <br /> WELL OR BORING LOCATION � g i f7 1 8 4��� �_ <br /> ry WELL AND BORING SEALING RECORD Sealm No. <br /> Coun Name Minnesota Unique No. — <br /> }��{ /� Mmnesota Statutes,Chapter 1031 or W-series No. � <br /> H�niiG �'1 ILeaveblankilnpiknown) <br /> Township Name Townshlp No. Range No. Section No. Fracuon�sm.�Ig.) Date Sealed Date Wetl or Bonng Constn,ctea <br /> Orono 117 23 �8 3�-�403 N�v -�i�i <br /> Numencal Street Adtlress or Fire Number and Gry of Well or Bonng Locatwn �"`a ( / <br /> 2392 Bald�� rB�R R� Qr0(�� DepthBeforeSealmg /G—• ft OriglnalDepth �� tl <br /> Slaw exad bcation ot w•ell or boring Sketch map ol well or bonng AO IFER(S) . STATIC WATER LEVEL <br /> in section gnd wrth'X'. � �� location, showing property Single Aqwfer � MulGaquifer <br /> lines,ioads,an wlding�• <br /> N � ��4 WELUBORING Measuretl ❑ Esumated <br /> ' �Water Supply Well ❑Monit.Well / <br /> � ` � ❑ Env.Bore Hole ❑Other _ �� R. �elow ❑above land wAace <br /> W -,r- -i-- -�— --;---E ING TY E(S) <br /> r <br /> � CAS P <br /> � � ---__.... , <br /> � � � � <br /> -,r- -�-- -;-- -�— .� � � � �teel ❑ Plastic ❑Tile �Other <br /> �c mr� � <br /> —�- -�-- -�-- -i— � i_�.__ CASING <br /> � � .�... Diameter Depih � Set m oversize hole9 qrvxialar space irrpa�y gro� <br /> �'�� [\'"` ��/ � <br /> '% ._..+ in.rrom O to� n. ❑ ves No O ves ❑No ❑urruwwn <br /> PROPERTV OWNER'S NAME in.irom to fl. ❑ Yes ❑No ❑Y�s ❑� ❑��"� <br /> Lauri� Q'Keefe <br /> Property ownefs rtwNrg a0tlress if diHerent Ihan wall location address indicaied above. in.hom to R. ❑ �es ❑� ❑Y� ❑� ❑�°�� <br /> P��• 17OX 1 1 2 7� SCREEWOPEN NOLE � <br /> 5� r aul s t il� 5 5 i 1 i Screen from �� to �� k. Open Hole from b 8. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �RodslDrop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstnictim <br /> �j Q/ �)�y,�i+ <br /> WM ownefs meilirq atlOress H Ailferent Man property owner's aAtlress indicated above. Typ9 ot ObsUuctiOns(DesCribe) ,�����1`•- ��/ ` Q" �U�i `/ <br /> Obstruclions removed? Yes ❑ No Describe <br /> PUMP �L. f� ('� <br /> 1� V�J I t.?�i" <br /> fiEOLO(i1CAL WTERIAL COLOR HApDNESS OF FROM TO Aemoved ❑ Not Present ❑ Other <br /> FORMATION <br /> M rq1 Ivqwn,inOicale esaneted formation bg from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASNC AIO B01iE HOIE: <br /> d r i f t � �� No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing PertoratioNRemoval <br /> in.from to ft. ❑ �a1ed ❑ Henwvad <br /> in.from to It. ❑ PeAoraled ❑ Renaved <br /> Type of pertorator <br /> ❑ omer <br /> GROUTING MATERIAL(S) <br /> / <br /> Grouting Material��A�� ���"'f� Q to� R ymds� bps <br /> from to 1L yards b�eps <br /> from to R yaid4 bps <br /> trom to R yaids 6eps <br /> REYARKS,SOUIICE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on praperty? ❑Yes No How n��/? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFlCATION <br /> This well or boring was sealed in axordence with Minnesota Rules,Chapter 4725. The irormt0a�caMa�rd in�is iaport is <br /> true to the best of my knowledge. <br /> � �?an Stodola t�ell nrilling Co. , Inc. 27I?2 <br /> Contrador Business Name f) j Licienss or RsgeBeean Ka <br /> .......-.....�l� *L"i �" � <br /> 1 1 <br /> fafn�e Signehne�'' Orls <br /> Jira Antonaon <br /> 1�^�^� Neme o/Person Seeling Wep or Bonng <br /> LOCAL COPY H V RJ <br /> ME-01r3403 �R <br />