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, , ,: ;�.;..�, � A�. ,;,,,_a, ._�� <br /> ;-���y � -<• „ �,, . � �, ;: v�-_ ' �� . � . . <br /> . . .. , . ..Y�� ., . . . . �. ' ._. ,`.� ":� <br /> . . . � _ , , • , . <br /> WELL OR BORING LOCA710N MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 13 9 4 4 3 <br /> WELL AND BORING SEALING RECORD Sealing No H <br /> County Name Minnesota Unique No. <br /> H@[lII@p121 Minnesota Sta�utes.Chapter 1031 or W-series No. � <br /> (Leave�lank�t not known) <br /> Township Name Township No. Range No Section No. Fraction(sm.�Iq.) Date Sealed Date Well or Boring Construded <br /> Orono 21� 23 20 . ,. 6/2�/98 <br /> Numerical Street Address or Fire Number and City of Well or Bwing Loca6on <br /> :�195 C.dsC� C:�l�Cle DepthBeforeSealing z�v tt OriginalDepih 1`.��ft. <br /> Show exact location of v.�ell or boring Sketch map ol well or bonng ApUIFER(S) STATIC WATER LEVEL <br /> in section grid wrth"X". � } �1 location, showing property �Single Aquifer � Multiaquiter <br /> v ��� lines,roads,and buildings. <br /> N WELUBORING $�Measured ❑ Estimated <br /> � � � � <br /> �Water Supply Well ❑Monit.Well <br /> -�- 'i-- � C <br /> —� , '�r. �'���� � '�""' ❑ Env.Bore Hole ❑Other V 1 ft. �below ❑ above land surtace <br /> f.� � � � : ..-.. ..- .. . .: <br /> � � � . _ ..,.��.,,-�,.,..P, <br /> __f_ ',__ _l__ __l__ -�..,..x*+' <br /> yy E � CASING TYPE(S) <br /> � � � <br /> � � � <br /> � <br /> � � � <br /> � � ""—""'"`"�� f�Steel ❑ Plastic ❑Tile �Other <br /> -�-- -�— --r- --r- .. <br /> � � � � r mde 'y6 ; � <br /> ' ' ' ' � An � { CASING <br /> -�-- -�— --�-- --�— <br /> ��i�� Diameter Depth Set in oversize hole? Annualar space initially grouted9 <br /> �l� S <br /> rmile� � in.irom o to ��7 ft. ❑Yes �No ❑ Yes ❑No ❑ Unknown <br /> PROPERTV OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> Juei �t�o lan <br /> Property ownei s mailinq add�ess if diHerent than well bcation address indicated above. in.from to ft. ❑ Yes ❑ No ❑ �es ❑ No ❑ Unknown <br /> � <br /> SCREEWOPEN HOLE <br /> Screen trom ro fl. Open Hole from `�7 to l`�� ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME � Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑Fill ❑ No Obstruction <br /> Well owner's mailing address if different than property owner's atldress indicated above. Type of Obstructions(Describe) �u�Q�7/ j�1�7� a nd �1 r f4� <br /> Obstructions removed? [�Yes ❑ No Describe <br /> PUMP <br /> Type submersible <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated tormation log from nearby well or twnng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing PerforatioNRemoval <br /> in.trom to ft. ❑ PeAorated ❑ Removed <br /> in.from to n. ❑ PeAoreted ❑ Removed <br /> Type of pertorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> �p t <br /> GroutingMaterial Pvrtiancl from � to� tt. yards _frY_ 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 OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes �No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was seated in accordance wi[h Minnesota Rules,Chapter 4725. The infortnation contained in this report is <br /> true to Ihe best of my knowledge. <br /> RES W�11 Drilliny 17L'�6 <br /> Contractor Business Name License or R istrallon l�o. <br /> � ' . .. / 1'„' <br /> / <br /> Authonzed Representative Signature ` Date <br /> Jcl1Tt�'S �,�d <br /> LOCALCOPY H <br /> 13 9 4 4 3 Name ol Person Sealing Well or Bonng <br /> HE-01434-03 2/97 R <br />