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MIEIL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH M�nnesota Well and Bormg rH l 4 4�3 9 � <br /> WELL AND BORING SEALING RECORD Sealing No. <br /> Cou�ry Name Minnesota Unique No — — <br /> Minnesota Stafutes.Chapter 1031 or W-series No. � <br /> Henne in (Leave blank il noi knpwn) <br /> Township Name Townshlp No. Range No. Section No. Fracbon�sm.-s Ig.) Date Sealed Date Well or Bonng Gonstructed <br /> Orono 11 23 20 I�fJO°37�� � cr � �^;�: <br /> Numerical Strcet AdOress or Fire Number and Ciry of Well or Bonng Locauon � � - <br /> 24�i1 C8.9C� Point Ad� Q=�Q� 5539 epthBetoreSea6ng ��tt OriginalDepth �[� h <br /> Show exad bcation of N�ell or boring '_ Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL. <br /> in section gnd with'X'. cat�e�, showing property �Sm le A uifer . <br /> � es!��?7ds,and buildings. 9 Q ❑Multiaquifer <br /> ry � WELUBORING (�Measured ❑ Estimated <br /> - - - - - -- - -- '��-s* wa�er s�,cpy we�i ❑r�«�a-weu � r <br /> '�^�f r` ❑ Em.Bore Hde ❑Other .�� R. �pelpw ❑aDove land suAace <br /> W _Y_ _Y_ _l__ __l__ E ��j \ CASING TYPE�S) <br /> � I i <br /> � <br /> -r- -�-- -�-- -i-- � ��� �,Steel ❑Plastic ❑Tile ❑Other ,. <br /> � � � i u mile _._..,.���`�/. � <br /> --�- -�- -�-- -�-- � CASING <br /> Diameter Depth � Set m oversize hde9 Mnualar space irntialy grouted? <br /> S �"� <br /> �~""'�—�' _.._...�.___._�.�.__ ? m-fram � to �U� ft. ❑ Ves �No ❑Ves ❑No ❑ Unkrawn <br /> P OPERTV WNER'S NAME m.irom to ft. ❑ Ves ❑No ❑ �� ❑� ❑ �^k^�'�'^ <br /> �ave�*4e 8n CanAastraci <br /> Prop9rty owner's ma�hrg adAress if ditterent than well location address indicated above. in.from to R. ❑ Ves ❑No ❑Y� ❑� ❑V��� <br /> C/��1�$�r Finsitat SCREEWOPENHOLE <br /> ���iZ: Jee John�on �3CJ'��L.lV �reenfrom ���? / to fr / , ft. OpenHolefrom to h. <br /> 3965 �i broadway oBS�„o� <br /> , �, <br /> Roas/Drav Pipe ❑ct,ea�vanre(S) ❑oebris ❑Fiu ❑No otscruaan <br /> Well ownefs meiYg address if different ihan property ownefs atltlress indicated above. Typ6 ot ObStnx.'tions(Oescribe) ��-'��U�1� �e��_j } ,�_/-!y'��G fr f�� � <br /> QbStflIC11011S fQfllOV6d? �85 ❑NO DBSCribB <br /> PUMP <br /> Ty� '`�!<':,e<.� r:,r���iy <br /> CiEOLO(i1CAL YATERIAL COLOR MAFDNESS OF FROM TO Rert�wed ❑ Not Present ❑ Other <br /> FORMATION <br /> If nal Ivawn,irdiceM eatirtated tormatbn log from nearby weli or boring. METfiOD 11SED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> i.� , �No/4wr/ar Space ExitS <br /> �`--f"��"r��� �f ❑ Mrx�lar space garted wi�h tremie PiPe <br /> ❑ Cesing PeAoraOwNRenaval <br /> �.� to R. ❑ Per(aated ❑ Rertavad <br /> �-� to R. ❑ Perbrared ❑ Renaved <br /> Type of peAorator <br /> ❑ Otl�er <br /> GROUTING YA7ERIAL(S) <br /> C,rarting 6,yteriel ^J/.:1/ f�1:�)!-�ho�n � ro L1� ft. yards � bsgs <br /> ham to It. yards bsqs <br /> hom to It. yards bays <br /> hom to_- fl. yards bps <br /> HEMARKS,SOI/RCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BOFi9iGS <br /> Other unsealed and inused well a boring on property? ❑Yes - No How many? <br /> LICENSED OR REGISTERED CONTAACTOR CERTIFICATION <br /> lhis we�a bwig was sealed in acoordence wiTh Minrresofa Rules,Chapter 4�25. The iMortnaOon contaned in Mis repott is <br /> m,a eo me oes�a�y a�ba9e. <br /> Don Stodala We2I Drilling co. , Inc. 27172 <br /> co�wac�a�e�esness Name �ioerrss or Hsyisb,ean r•o. <br /> � , <br /> � yj-'���-•' ��. �� `�LW <br /> �SiBmaNre OWs <br /> �---- �-��-"•�•`-�ls�v�.✓ <br /> LOCAL COPY H 14 4 4�9 �d Rarsnn Se�alig WeI w Bonng <br /> HE-01�34-03 2/97 R <br />