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WELL OR BORING LOCA71oN MINNESOTA DEPARTMENT OF HFALTH M�nnesota Well and Bonng i ���� �� <br /> WELL AND BORING SEALING RECORD Sealing No H 7 <br /> County Name Minnesota Urnque No. � --- � <br /> Iiennegin Minnesota Statutes,Chapfe�1031 oeW berkes�NooWn' <br /> Township Name Township No. Range No. Secfion No. Fracuon�sm.-i Ig.) Date Sealed Date Well or Bonng Constructetl <br /> Orono 118 23 36 1�3-a00 j' aCj �i� <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Localion s,, / ♦ <br /> Sd7 Ferndale Rd N� Orono 5539I Depthee�oreSeai�ng ��/J n OriginaiDepth f� n <br /> Show exact location of N�ell or boring Sketch map of well or nng ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X'. location, sho p rty Single A�uifer ❑ Multiaquifer <br /> lines,roa ,and buil <br /> N WELUBORING Measuretl ❑ Estimated <br /> � �y��� az Water Suppty Well ❑Monit.Well � t <br /> _T_ _T_ _'__ 1 `.J . - <br /> ' � ❑ Env.Bore Hole ❑Olher ft �]below ❑ above land surface <br /> W --i-- -i-- -i— --i— E � � CASING TYPE�S) <br /> � � � � <br /> � � � � .: <br /> —�- -i-- -i-- --�- �; Steel ❑ Plastic ❑Tile � Other <br /> ,�mee <br /> --`- 1 ._.._.._.,___ _ h.` CASING <br /> -�-- -�-- --i-- <br /> ' ' ' � Diameter Depih / Set in oversize hole7 Annualar space inilially grouted? <br /> �\ ,�,� <br /> ��m;�� � �= in trom Q to � 1 n. ❑ Yes �No ❑ �es p No ❑ Unknown <br /> PROPERTV OWNER'S NAME in.from to R. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> Prope owner s m •a res if diflereM than well 1 ti ddr s �a d above. in.from [o ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> / � <br /> L <br /> Screen from � �/ to r ys R Open Hole from to ft. <br /> OBSTRUCTIONS <br /> - WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑Debris ❑ Fill �No Obstruction <br /> Well ownefs mailing adCress if tlitterent than property owner's atlAress indicated above. Type of ObsVUCtions(Describe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> 6EOLOfi1CAL MATERIAL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> II not known,indicate estimated formatbn log from nearby well or bonng. MET OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE MOLE: <br /> � �No Annular Space Exists <br /> �� 1 ° ���� ❑ Annular space grouted with tremie pipe <br /> f � ❑ Casing Perforation/Removal <br /> in.trom �o ft. ❑ PeAorated ❑ Removed <br /> in.trom to ft. ❑ PeRorated ❑ Remrned <br /> Type o�peAorator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) <br /> / <br /> �! .�•- <br /> Grouting Matenal N�/�`/ ��-��'`I from � to� tt. yards /� begs <br /> irom to ft. yards beys <br /> from to ft. yards bags <br /> from ta__ R. ya�ds bags <br /> ' REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on propeAy? ❑Yes No How many? <br /> LICENSE6 OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring wes sealed in accordance wiM Minnesota Rules,Chapter 4725. The information contained in lhis repat is <br /> true to ihe best of my knowledge. <br /> 8on Stodo3.a Well Drillin� CQ. , Inc. 27I72 <br /> Conhactor Bus� ess Name License a Regishafion�:o. <br /> > .�� F��.-�`� .f�J �L' � <br /> ./� <br /> AuMo ed Representefive Signeture Date <br /> ,''\ <br /> �y-.,.., ���y ...�;Y:f�i�Y\� <br /> LOCAL COPY H 15 8 fi 7 9 Name o/Person Seeling WeU Bvnng <br /> HE-01434-04 8/98 R <br />