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<br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �g Q 5 7 5
<br /> County Name
<br /> WELL AND BORING SEALING RECORD Minnle90 a�Unique Well No.
<br /> Minnesota Statutes,Chapter 103! or W-series No.
<br /> Heanapin «ea�e o�a�k���o,k�ow�,
<br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
<br /> �' Orono 117N 23W 6 NE � I�W June 25, 2009
<br /> ,
<br /> GPS Latitude____ degrees ____ minutes___ . seconds Depth Before Sealing �,v tt. Original Depth ft.
<br /> �� LOCATION: Longitude_ degrees_____ minutes seconds �'
<br /> —�--"-- AQUIFER(S) STATIC WATER LEVEL
<br /> Numerical Street Address or Fire Number and City of Well or Boring Location '��Single Aquifer ❑Multiaquifer 6/25/09
<br /> 6695 Bayside �� 0r0110 SJ3V�i WELL/BORING [�Measured i]Estimated DateMeasured _ _
<br /> [�Water-Supply Well ❑Monit Well
<br /> Show exact location of well or boring Sketch map of well or boring r I Env.Bore Hole Other 130 ft. below above land surface
<br /> in section grid with"X." location,showing property ❑ — � ❑
<br /> f�,��� � lines,roads,and buildings. CASING TYPE(S)
<br /> ; �
<br /> '� �'i� .������• �Steel [;Plastic L;Tle ❑Other
<br /> �
<br /> � --'-----'--- ---�---'-'"- WELLHEAD COMPLETION �
<br /> � W ; ; ; ET {j��
<br /> ;� __;_____;____;___.r__ �^q Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset
<br /> 'h Mae ^" [�i Pitless Adapter/Unit ❑Buried ❑Well Pit
<br /> ' --j--- --�-----�-- --�— I ❑Buried
<br /> L ❑Well Pit
<br /> S ❑Other
<br /> �1 Mile--� �- '�"'»�� �� ❑OthBf
<br /> P OPE TY O NER'S ME/ OMPANY NAME CASING(S)
<br /> Gat�er�ne �a �or Homes
<br /> y Diargeter O Deptly,� Set in oversize hole? Annular space initially grouted?
<br /> Propert owner's mailing address if difterent than well location address indicated above 4 1
<br /> ib� Raiiway st W in.from to ft [�Yes ❑No �Yes ❑No ❑Unknown
<br /> Loretto. 1� 55359 in.from �o ft. ❑Yes
<br /> ❑No ❑Yes �No �;Unknown
<br /> _____in.from to____ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
<br /> WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
<br /> Catheriae Taplor H�op[ 1 Q T
<br /> Well owner's mailing address if different than property owner's address indicated above SCreen ffom a�" to �`� ft. Open Hole frOm � to ft.
<br /> � r�,
<br /> OBSTRUCTIONS
<br /> z �Tnods/Drop Pipe ❑Check Valve(s) J Debris ❑Fill ❑No Obstruction
<br /> Type of Obstructions(Describe) drop pipe
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed7 ��Yes ❑No Describe
<br /> FORMATION
<br /> . If not known,indicate estimated formation log from nearby well or boring. PUMP tr
<br /> Type �uV�f, _
<br /> ., [�L'Removed ❑Not Present ❑Other
<br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
<br /> �No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
<br /> in.from to ft. ❑Perforated ❑Removed
<br /> in.from_,__ to _ft. ❑Perforated ❑Removed �
<br /> Type of Perforator
<br /> L Other _
<br /> GROUTING MATERIAI(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> GroutingMaterial A@8t �em8I1C from � _ to 17� ft. yards i�' bags
<br /> from to ft. yards__ bags
<br /> .______ from to ft. yards bags
<br /> OTHER WELLS AND BORINGS
<br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? J'Yes ',$No How many7__ ___ _
<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
<br /> is true to the best of my knowledge.
<br /> Stevene Drilling � Bav. Svc. Znc. 2255
<br /> ic see Business Name License or Registration No.
<br /> , � �. , 556 6/29IQ9
<br /> c�— ------__---- — ,
<br /> ed Representative Signatur Certilied Rep.No. Date
<br /> ' ---
<br /> H 2 80 5 7 5 Tim Stevene
<br /> `�`�, LOCAL COPY - --- __ _ _—— — �
<br /> Name ol Person Sealing Well or Boring
<br /> HE-07434-11 IC#140-0423 2iosR
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