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wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Seai ng No. ell and Boring H 112 9 � 3 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> q (Leave blank if not known) <br /> Township ame Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date�Vell or Boring Constructed <br /> Orono lI7 23 08 ' ' U(/ Co <br /> Numerical Street Address or Fire Number and City of Well or Boring Location � <br /> 1!.�/_ n�1.1... t1�.,� n� Depth Before Sealing �.�L.�` ft. Original Depth �d ft. <br /> 'YY°i �Li1441 r�A Att <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, wing property Sin le A uifer <br /> lines ds, d buildings. 9 4 ❑ Multiaquifer <br /> N WELUBORING �easured ❑ Estimated <br /> � � � Water Supply Well ❑Monit.Well � <br /> ---- -i-- -;-- --;-- t ,�` <br /> � � <br /> �� ��\ ���� ❑ Env.Bore Hole ❑Other �ft. �below ❑ above land surface <br /> � � � � <br /> � � � ` \ <br /> � ,. <br /> W --i- -�-- --i-- --i-- E �� �� �� �CASING TVPE(S) , <br /> � � `.- <br /> i � � Y , <br /> --�- -i-- --�-- --�-- '-� Steel ❑ Plastic ❑Tile ❑Other <br /> u mile ,�(,f <br /> __L_ _J__ __J__ __�__ � �"r CASING <br /> ,.N <br /> Diameter Depth r Set in oversize hole? Annualar space initially grouted? <br /> l� � ""�J�� ��� �� � � <br /> q{�-1 mile�s ;� m.from to ft. ❑ Yes '[�lo ❑Yes ❑No ❑ Unknown <br /> I I <br /> PROPERTY OWNER'S NAME _ in.from ta ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> Property owner's mailing address if diHerent than well location address indicated above. in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> i /�,/'�1 <br /> Screen from�to `4'L fl. Open Hole from to ft. <br /> O B ST R U CTI O N/D E B R I S/FI L L <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? ❑ Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BEIWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � ' `�No Annular Space Exits <br /> ,: <br /> . ❑ Annular space grouted with tremie pipe <br /> r <br /> �' ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in,from to n, ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUT�NG MATERIAL(S) <br /> �� t <br /> Grouting Material r 06m �_ 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 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. <br /> zx� sL�ia �a.�. �x�.u� co., ��. 27I72 <br /> Contractor Business Name / _ License or Registration No. <br /> .�,,.-' /_: J !- _7� <br /> f J <br /> ori��p _ arve Signatuie '..- "" Date <br /> , i � : <br /> � ��t_ ;.;� A_ �.�t��__./"t.��:`�..1�.�r;-�:� : <br /> r � Name of Person Sealing W�or Boring <br /> LOCAL COPY H � � �` � � � � <br /> HE-01434-02 k <br /> 10/95R E <br />