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� .""=%;�'', <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ��� <br /> .OR BORING IOCATION yyELL AND BORING SEALING RECORD sea''"9"°. i H _ <br /> �ry Name Minnesota Unique Well No. <br /> denn�pin Mmnesota Statutes.Chapre��031 or W-series No. <br /> M1.ev.w�x n�rn x�w�� ------ <br /> ownship Name Township No. Range No Secuon No. FracUon�sm.-i Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 11? 23 18 , ,. 5/9100 <br /> Numencal Streel Adtlress or Fne Number and Cyrty of Well or Bonng Location s� <br /> �.�8.�.. Fa�ernes� pQi�tr �d• d�On� Depth Betorr,Sealing 9v _R Original Depth 96 n <br /> Show exact location of N�ell or bonng Sketch map of weu or bonng AOUIFER(S) STATIC WATER LEVEL <br /> in section gnd with"X". N � locatwn, showing property �S�ngle Ayurter � MultiaquAer <br /> lines,roads.and buildi s. <br /> N WELUBORING �easwed ❑ Esumatetl <br /> � � � � <br /> [zWater Supply Well ❑Monit.Well <br /> -�- -�— � 7 <br /> ❑ Env.Bore Nole ❑Other _ �•_tt. [j'�ielow ❑ aDove land surface <br /> W --�- - -- - -- -- -- E (� CASING TVPE(S) <br /> � � � <br /> � � � N <br /> —�- -�- -;— --�— � �( F / [�]LStee� ❑ Piastic �Tile ❑ Otne� <br /> I I }2mile �� f <br /> --�- -�-- -�-- --1-- � IN ;' CASING(S) <br /> ' S ' \ k' � / � Diameter Depth Set in oversize hole9 Annular space initially grouted? <br /> ��"" / bt <br /> �i mee� Jl f ,' ��(-' � in.Irom� to� fl. ❑ Yes �lo ❑ �es ❑No ❑ Unknown <br /> � 1 <br /> PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> �cti Christer�son <br /> Property ownei s mailmg address it ditteren�than well locauon address indicated above. in.hom to fl. ❑ Ves ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN MOLE <br /> Screen from �� to 7� R. Open Hole from to R. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Dro Pi e ❑Check Valve(s) ❑ Debris <br /> [][ p p ❑ Fill ❑ No Obsiruction <br /> Well owner's mailing address il ditterent than property owner's address indicated above. Type of Obstructions(DesCribe) ,�u�,� and ��p� <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP <br /> Type ��t'r <br /> GEOLOGICAL MATERIAL COLOR �ARDNESS OF FROM TO �emoved ❑ Not Present ❑ Other <br /> FORMATION <br /> If not krawn,iMicate estimated tormation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> C�Jo Annular Space Exists <br /> ci r i f t � � ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to fl. ❑ PeAoraled ❑ Removed <br /> in.from �o h. ❑ Pertorated ❑ iiemoved <br /> Type of peRorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag oi cement=941bs.,one bag oi bentonite=50 Ibs.) <br /> Grouting Material �'ortlaAd from �� to � fl. yards � bags <br /> irom to ft. yards bags <br /> from to ft. yerds bags <br /> from to__ tt. 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 p No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> 8E5 Wei3 �ril2ia� 2'7276 <br /> Contractor Business Name License or Regishafion fro. <br /> � <br /> �. �_ <br /> Aufhonzed R e've 'nafure � - Date <br /> Jam�s Lea <br /> :_.i ji;p�,. ;��j�v u ����j� Name ol Person Sealing Wel/or Bonng <br /> fl �f <br />