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Minnesota Well and Boring 4 3 9 3 � <br /> WELL OR BORING LOCarION MINNESOTA DEPARTMENT OF HEA�TH Sealing No. H <br /> �o�ntY N�me WELL AND BORING SEALING RECORD M���esota���q�e No. <br /> �p„„� }� Minnesota Statutes.Chapter 1031 or W-series No. <br /> Gt,�1Gp1 F� (Leave blank if nol knownl <br /> Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br /> Orono 117N 23W 7 NF„NE�„SE�„ 3/2/94 or Boring Constructed <br /> •� Numerical Street Address or Fire Number and City of Well or Bonng Location <br /> 1220 Loma L i nda, 1'RJ�n�� i`Nl ���17'F Depth Before Sealing T�� ft Onginal Depih ft. <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level ❑Accurate � <br /> in section grid with'X". location.showing property lines. <br /> roads,and buildings. ❑Approximate <br /> N <br /> � � � � <br /> __ ___ '-_ _i <br /> �Single Aquifer ❑Multiaquifer ft. below above land surface <br /> i i i i <br /> _i_ _�_ _i_ _i_ CASING TYPE <br /> W i i i i E <br /> � � � � T <br /> -r -�- -r- -r '�' <br /> i i i i �Steel ❑Plastic ❑Tile ❑Other <br /> mile <br /> _i i i i_ � <br /> i i i i <br /> S Screen from� to � tt. Open Hole from to ft. <br /> ��mi�e—�I OBSTRUCTION/DEBRIS/FILL <br /> ❑Obsirucfion ❑Debris ❑Fill <br /> PROPERTY OWNER'S NAME <br /> Dr. W att PNoe <br /> Type of debns/obstruction <br /> . Maiting Address il different ihan property address indicated above. <br /> Obstruction/Debris/Fill removed7 ❑Yes ❑No <br /> PUMP <br /> �Removed ❑Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversrze hole? Annular space initially grouted7 <br /> � If not known,mdicate estimated formation log irom nearby well or boring. <br /> �in.from _.Si--to —.J3— ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAH SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists <br /> ❑Annular space grouted with iremie pipe <br /> ❑Casing Perforation/Removal <br /> � � in.from to ft. ❑Perforated ❑Removed <br /> '��'�- in.from �o fl. ❑Perforated ❑Removed <br /> Type of perfora�or <br /> MA 1` y� ❑Other <br /> •-• GROUTING MATERIAL <br /> . Grouting material Fleat CPmPnt from �to 1�ft. yards�bags <br /> from to fl. ya�ds bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEAI�NG <br /> from to ft. yards bags <br /> trom to fl yards bags <br /> UNSEALED WELI�S AND BORINGS <br /> Other unsealed well or boring on property? Q Yes ❑No i n u se <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 ihe best ot my knowledge. <br /> Stevens Drilling & Env., inc 8665� <br /> Contractor Business Name License or RegistraGon No. <br /> — _ 3j4/94 <br /> Authorized Repiesentative Signature Date <br /> LOCAL COPY H 4 3 9 3 5 ph�1]i p Otto <br /> Name ol Person Sealing Well or Boring <br /> . HE-01434-01 <br />