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wELL OR BOR�NG LOCA71oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL AND BORING SEALING RECORD Sealing No. H 10 712 6 <br /> County Name Minnesota Unique No. <br /> Hennepia Minnesota Statutes,Chapter f031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well r��1q Const�y.(cted. <br /> Orono ll�j 23 33 � � � 8J�/46 <br /> ��1 �! .R.-3,�;n <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> �25 R kberry K��.�. Depth Before Sealing 17�. ft. Original Depth �11 ft. <br /> Show exact location of well or boring Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property �Single Aquifer ❑ Multiaquifer <br /> �lines,roads,and buildings. <br /> N WELUBORING 4cMeasured ❑ Estimated <br /> �Water Supply Well ❑Monit.Well <br /> - - --i-- --;-- --;-- <br /> E ❑ Env.Bore Hole ❑Other �Q_ft. [�elow ❑abpve land surtace <br /> �-...�..��. <br /> W —�- -i-- -i-- --i-- E CASING TYPE(S) <br /> � i � <br /> � � <br /> --�-� � i � � � <br /> -�-- --;-- --�-- [*Steel ❑ Plastic ❑Tile ❑Other <br /> Ya mile <br /> -�- -�-- --�-- ---I-- � i CASING <br /> - � Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> lll""" S <br /> �w--t mi�e� � in.from�_ to�� ft. ❑Yes [�No ❑ Yes ❑No ❑ Unknown <br /> I <br /> PROPERTY OWNER'S NAME in.from _ to ft. ❑Yes ❑No ❑Yes ❑No ❑ Unknown <br /> Pro o n 's aili g e ifferent than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> Screen from 3�,? to�_ ft. Open Hole from to ft. <br /> OB STR U CTI O N/D EBRI S/FI LL <br /> WELL OWNER'S NAME �Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill �� ������n m <br /> Obstruction/Debris/Fill removed? � Yes ❑ No <br /> PUMP <br /> Type�ai. <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log f�om nearby well or boring. METHOD USED TO SEAL ANNULAH SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � No Annular Space Exits <br /> c�rift 0 1� <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal e <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material ���'�,���+�� from 1 71 to�_ ft. yards � bags <br /> from to ft. yards bags <br /> \_ <br /> from to tt. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes �No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> R.E.S. iaell Drillin� 27276 <br /> Cont�actor Business Name License or Registration No. <br /> �- � C <br /> Authorized Representafive Si nature '� � � D e <br /> James Lea <br /> r Name of Person Sealing WeII or Boring <br /> LOCAL COPY H � � � � � p <br /> HE-01434-02 10/95R <br />