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;-T�7E5 �e\\�� `��;��.��—` <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �13 7 9 4 <br /> County Name <br /> WELL AND BORING SEALING RECORD Mnnlegoa�UniqueWellNo. <br /> �[I� in Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank il not knowni <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 33 NW NS , 2( U C� � <br /> GPS Latitude degrees minutes seconds /) <br /> / <br /> LOCATION: Depth Before Sealing / � ft. Original Depth/�v ft. <br /> Longitude degrees minutes seconds p IFER(S) STATIC WATEfl LEVEL <br /> Numerical Sireet Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> O�� � $t D� T, �� �UBORING �Measured ❑ Estimated <br /> � x7A TUl ater Supply Well ❑MoniL Well � <br /> Show exact location of well or boring ,�,� (;'- p of well or boring /` <br /> in section grid with"X" �� "�' ��howing property ❑ Env.Bore Hole ❑Other �v ft. �elow ❑above land surface <br /> N � Iines,roads,and buildings. CASING TYPE(S) <br /> -- - - -- - - -- -- A J <br /> r j �; , h �teel ❑Plastic ❑Tile ❑Other <br /> -�- -�-- -;— —;-- ����`,� �/ WELLHEAD COMPLETION <br /> W E ,a/ <br /> � � � � ('` � Outside: ❑Well House Inside: ❑Basement Offset <br /> -;-- ;-- -;-- --�-- � , � j <br /> p� <br /> �^'�� � ❑ Pitless AdaptedUnit ❑Well Pit <br /> --- -i-- -i— --�— <br /> ❑Well Pit - ❑Buried <br /> S <br /> , ` t , <br /> �rmee� �t ._ -.��. , uried <br /> PRtO1P,.EiRTY OWNER'S NAME/CO PANY NAME CASING(S) <br /> .valJ�$t� � �t Diameter Depth � Set in oversize hole? Annular space initially grouted? <br /> Proper�y owner's mailiny address if different than well location address indicated above � �� <br /> in.from� to //li� ft. ❑Yes �io ❑Yes ❑No ❑Unknown <br /> 7745 Polarfs Lane <br /> Maple Grave, �t 55313 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if diNerent than property owner's address indicated above Screen from���10��ft. Open Hole from i0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill [�Vo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑YBS ❑ No DeSC�ibO <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> � u ! .�. Type <br /> ❑ Removed [�lot Present ❑ Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> . p/ No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> f� <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S)' (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> ,r1 � �../.�- / <br /> Grouting Material ��/%'!T�'��.�"�Nrbfii Q to��ft. yards _� bags <br /> from to tt. yards bags <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 sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> 1)on Stodols Well Drilli Co., Inc. 27272 <br /> Contractor Business Name Licer,se or Registration No. <br /> �-�z-a3 <br /> �t z eprese tative Si _ Date <br /> LOCAL COPY H 2 i 3 7 9 Jlu� �t�1�3� <br /> Name ol Person Sealing Well or Boring <br />