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_ .� , <br /> . _. , . .qn,. < <br /> , .. ,.. <br /> ; _. . . ;, . . <br /> , <br /> wELL oR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„� w <br /> . County Name <br /> WELL AND BORING SEALING RECORD Minne9oNa Unique Well No. !�' <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> .i ia vc biank�i�not known) <br /> �� Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Weli or Boring Constructed <br /> : Orono 1 7 2 09 �1-�t�01� Q <br /> GPS Latitude degrees minutes seconds � <br /> LOCATION� Depth Before Sealing �� _ft. Original Depth �� ft. <br /> Longitude degrees �' minutes seconds p UIFER(S) S7ATIC WATER LEVEL <br /> � Numerical Street Address or Fire Number and Ciry of Wel!or Bo�ing Location �ingle Aquifer ❑Multiaquifer <br /> 2465 Fc�ench Lake Rd, Orona 55391 WE4L/BORING vleasured ❑Estimated <br /> �Water Supply Well ❑Monit.Well �.. � <br /> � Show exact location of well or boring Sketch map ot well or b ing �t <br /> in section grid with"X" location,showing prope y ❑ Env.Bore Hole ❑Other �� ft. �low ❑above land surface <br /> lines,roads,and buildin s. <br /> N CASING TYPE(S) <br /> � � � � � ;. <br /> � -'�— —� <br /> i teel ❑ Plastic ❑Tile ❑Other <br /> � � � � <br /> W -- - - -- -i-- --i— E A` i WELLHEAD COMPLETION � <br /> � � � � i` ``y (C _ <br /> � � � � � Outside: ❑Well House Inside: ❑Basement Offset �� <br /> -;- ;-- -;-- --�-- � �.. <br /> ' �'"'� � �'itless Adapter/Unit ❑Well Pit ' <br /> ,. -�-- -i-- -�-- --i-- � � /J . <br /> � S � j ' ❑Well Pit ❑Buried <br /> lll��� � f <br /> �I�--r mde� ��/ �Buried <br /> I <br /> ' PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diamet �{ Depth ! Set in oversize hole? Annular space initially grouted? <br /> � Property owner's mailing address if erent ihan well location address indicated above L_ /� <br /> � in.fromS� to�ft. ❑ves �o ❑ves ❑ No ❑unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown i <br /> in.f�Om t0 ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREENlOPEN HOLE � <br /> t f <br /> ��� Well owner's mailing address if different than properry owner's address indicated above Screen from_��t0__i�.�ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �IVo Obstruction <br /> l� <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑YES ❑ NO DOSC�ibB <br /> FORMATION <br /> � If not known.indicate estimated formation log from nearby well or boring PUMP � <br /> � / Type <br /> ❑ Removed [�lot Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> O oA'O in.from to ft. ❑ Perforated ❑ Removed <br /> �v <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of be,ntonite=50 Ibs.) <br /> r /'� <br /> Grouting Material �'��f�f���t�om_�to /� ft. yards _-�[�1 bags - <br /> from to ft. yards bags <br /> Y <br /> from to ft. yards — bags - <br /> OTHER WELLS AND BORINGS <br /> ' REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 seaied in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. $ <br /> n«� stoaoia c��.� n�lz� eo,. I�. 27272 <br /> Contracfor Business Name License or Registration No. <br /> > .�- 1. � � <br /> z epresenta�ve Si ture Date <br /> LOCAL COPY H 2 2 2 614 �� � ��s~~ <br /> Name of Person Sealing Well or Boring <br />