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wELL Oq BORING LOCAT�ON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i � � <br /> WELL AND BORING SEALING RECORD Sealing No IH 1�. ,_:9�9 <br /> Counry Name MinnesO:a Unique No. � - � <br /> (� Mmnesota Statutes,Chapter 1031 or W-senes No. � <br /> f?��i�� in ILeaveDianpAnotknown� _.. <br /> Township Name Township No. Range No Section No. Fracaon�sm.-s Ig.) Date Sealed Date Well or Boring ConsVuctetl <br /> �rono I 7 2 2 12 tJt�17�� 3 /1'}f1� �} <br /> Numerical Street Address or Fire Number and City of Well or Bonng�ocanon / � � <br /> 3555 Fredrick Ave, Orono 55391 DepthBetoreSeahng /37 R O�iginalDepih �_h <br /> Show exact Iceatlon of K•ell or boring Sketch map of well or bor�ng UIFER(S) STATIC WATER LEVE� <br /> m section grid with"X". � lotahon, showing property Single Aywter � Mulhaqwter <br /> I es,roads:;antl buildings <br /> N f'��,_y,..��.�� <�-��...� `�..l�s�iL WELVBORING Measured ❑ EsUmated <br /> Water Supply Well ❑Monit.Well � <br /> ❑ Env.Bore Hole ❑Other _ � ft. �elow ❑above land surtace <br /> I I I I _._...,..__.. <br /> W --r- -�-- - -- --�-- E _ CASING TYPE�S) <br /> � <br /> � � � +� <br /> � <br /> � � � � <br /> —�- -�- -i-- --i-- Steei ❑ Plastic ❑Tile ❑Omer <br /> 'F mrle <br /> --�- ' I ' � .._. CASING <br /> -�-- -�-- --i-- <br /> _____ Dia�tql Depth ( Set in overs¢e hole7 Annualar space initially grouted? <br /> S <br /> ��m�� in from � to /33 tt ❑ ves �No ❑ Yes ❑No ❑ Unknown <br /> PR PER OWNER'S NAME m.from ro ft. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> �h-�Llis Anderson G7I-9a52 <br /> Properry owner's maihng address if diHeren�than well location address indicated above. in.hom to k. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE � <br /> I j� � <br /> Screen from�to L� h. Open Hole from ro H. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Dro Pi /� �� s� <br /> p pe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction <br /> Well owneYs mailing atldress it diflerent than property owner's address indicated abova. Type of Obslructions(Describe),,,,`N1U!��1� • -.:('�'� 4" /""�//!/� � <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP /� <br /> 7ype S�G �'�..1MP <br /> OEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> 11 rat krawn,indicate estimated fortnatbn log trom nearby well or boring. METHOD USED TO SEAL ANNUUR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � �No Annular Space Exists <br /> ��,J { �.�� :�:"1 <br /> ❑ Annular space grouted with tremie pipe <br /> _�' � ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> in.from to fl. ❑ PeAoreted ❑ Removed <br /> Type of peAorator <br /> ❑ omer <br /> GROUTING MATERIAL(S) <br /> Grouting Material�F���,�"'^�1rom � to�L 11. yards �.�e_ bags <br /> from to h. yards begs <br /> from to h. yards begs � <br /> from to__ ft. yards begs <br /> REMARKS,SOURCE OF DATA,DIFflCULT1ES IN SEALING OTHER WELLS AND BORINCaS <br /> Other unsealed and unused well or boring on property? ❑Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordence with Minnesota Rules,Chapter 4725. The information confeined in Mis report ia <br /> true to the best of my knowledge. <br /> Don Stodols WeZl Drillfng Co. , Inc. 27I72 <br /> Contractor Business N e License a Regishation fio. <br /> r� � <br /> ��'_ '-�-� �� _ <br /> .a �� � <br /> utho'ed Representative Signetwe.. Dafe <br /> 1 <br /> �` �.'7-.!'v �ati,_,/C?,..L�Y.`.., <br /> Name ol Pers6n�Sealing Well or Boring <br /> LOCALCOPY H <br /> HE-01434-04 8�9$R <br />