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� <br /> � �,a: .. ., v�. �_=_ .. _. <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Bonng � � <br /> .. WELL OR BORING LOCATION 9 I H �4����' <br /> WELL AND BORING SEALING RECORD Sealin No ,� � <br /> � Counry Name Minneso:a Unique No � - � <br /> i{2T1D2�31 Tl Minnesota Sta�utes.Chapter 1031 or W-senes No. <br /> ILeave Dlank it nol known) <br /> Township Name Township No. Range No. Section No. Fractwn�sm.-s Ig J Date Sealed Date Well or Bonng Constructetl <br /> � Orona 2�85 23 35 � ~ '' _� Jtsrv� �'ic? <br /> �.Numerical Street Address a Fire Number and City of Well or Bonnq Location / <br /> t�O r3 Lon� Lake BL VC�. Orono, �jj� Depih Bebre Sealing�_N. Original Depth � n� <br /> f Show exact location of N�ell or bonng 5�3 5 5 Sketch map ot well or bonng AO IFER(S) STATIC WATER LEVEL <br /> in section gnd wrth"X' . bcation, showing property Single Ayurfer ❑ Multiaquder <br /> � lines,roads.and buildings. <br /> N �'�_j', y WELUBORING �Measured ❑ Esnmated <br /> � � � � r .. . Water Supply Well ❑MoNt.Well I/ � <br /> -�- -�-- --;-- --� : . L./ <br /> I I � `�� � : ❑ Env.Bore Hole ❑Other _ � r R. �below ❑ above land surtace <br /> ' � � f <br /> W --�- -i-- -;-- --i-- E CASING TVPE(S) <br /> `, <br /> � � � <br /> � � � � T <br /> , —�- -;-- -i-- —�-- � �� � k Steel ❑ Plastic ❑Tile ❑ Other � <br /> � � ' � u mr�e � j <br /> --`- -- ' CASING <br /> -� --I-- --i-- I � � � <br /> � � Diam ter J Depih � Set in oversize hole7 Annualar space initially grouted7 <br /> LL�� S J� 1-�4! � � �� ves �No ❑ ves ❑No ❑ unknown <br /> �t mr�e—�e 3 in.irom to �ft. ❑ <br /> I <br /> ��� PROPERTY OWNER'S NAME in.from to R. ❑ Ves ❑No ❑ Yes ❑No ❑ Unknown <br /> �{urt Greenl.� <br /> Proparty owner's mailing a0dress B tliffereN than well location adaress indicated above. in.from to tt. ❑ �es ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN MOLE� r <br /> Screen from �� to� R. Open Hole from to R. <br /> OBSTRUCTIONS <br /> � WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑Fill �No Obstruction <br /> Well owoer's mailing aAdress if diflerent than property owner s atldress mdicated above. Type of ObsttuCtionS(Describ6) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> OEOLOOICAL MATERIAL COLOR „ARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> If rat known,inOitate estimeted formation log from nearby well or boring. M1�ETF�IOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BOHE HOLE: <br /> R�J No Annular Space Exists <br /> / ��3 ��� ❑ Annular space grouted with tremie pipe <br /> . � ❑ Casing Perforation/Removal I <br /> in.from to R. ❑ Pertoreted ❑ Removed <br /> in.irom �o ft. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> / <br /> 1'- /j��� �� /� <br /> Grouting Material L�-��� �� 'f'�"'`��r'(rom �^" ro�t� ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards begs <br /> irom ta_— ft. yards bags <br /> REMApKS,SOURCE OF DATA,dFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How meny? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordence wfth Minnesota Rules,Chapter 4725. The information contained in Mis repoh is <br /> true to itie best of my knowledge. <br /> �UN STODOLA WELL DRILLIN� C(J. , INC. 27172 <br /> Contractor Business N me License or Registrafion fa. <br /> ;�"�� ,-_ �.- ''i '�" / _ <br /> o epresentetive Signature Dete <br /> �\.rl ���_. .. ., �. �" .a.f <br /> LOCAL COPY <br /> H 9 8 9 Name ol Person Sealing Well a Boring <br /> � <br /> �i HE-01434-04 8/98 R f <br />