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<br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I a °'4�"7 ��
<br /> County Name
<br /> WELL AND BORING SEALING RECORD Mennlego a�Unique Well No. ~� +_ r
<br /> or W-series No.
<br /> ��enrr�iz� Minnesota Statutes,Chapter 103I ,�o��ab���k„�o�k�ow�,
<br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Construc[ed
<br /> �cc�rx> 11R 3 35 ?�� ��d �.- ,f'C�, �-�p /t�
<br /> GPS LOCATION-decimal degrees(to four decimal places) ��� f
<br /> ` Depth Before Sealing ___ ft. Original Depth.,.. ft. �
<br /> � Latitude_ __.__ ___ Longitude '
<br /> � � �� Q IFER(S) STATIC WATER LEVEL
<br /> Numerical Street Address or Fire Number and City of Well or Boring Location �'� ingle Aquifer i. J Multiaquifer /� , l
<br /> easured Estimated Date Measured� !���
<br /> �� �. rtle��aoc3 R� �rona 55391 W-E�,"BOR�"G �' �� .�_F>>`d'}�
<br /> � �,�water-Supply Well j Monit.Well �
<br /> : Show exact location of well or boring Sketch map of well or r�' ����Env.Bore Hole �� ' '
<br /> ' in section grid with"X° location,showing prope ty � --1 [ ]Other . . _ _.__ _. . ___ ft. �below �._above land surface
<br /> � lines,roads,and buildi s. ��
<br /> ' N � / CASINGTYPE(S) ,
<br /> � ��...�.�.�. . � ey�, / `
<br /> . .--- -` `-- � d -- ------. .__ -
<br /> , , �
<br /> j ,�; �, Steel , �Plastic '� �Tile �', �Other _.__ _ .
<br /> '� "�'-- --�--- ---`- ---�-- � 0 � WELLHEADCOMPLETION ��
<br /> + W � � � � E'(" �
<br /> 1 ' ' ' ' I " � Outside: Well House i At Grade Inside: '
<br /> , ______ ______ __,__ ___,_ ,_Basement Offset
<br /> 'h Miie � �itless AdaptenUnit __'Buried ❑Well Pit
<br /> ------ ------ ---�-- ---:-- 1 - d
<br /> ` ,, ,�Burie
<br /> � I I S I I � �l Well Pit __ - ._.-------
<br /> 3 1 Other
<br /> �--1 Mile� �_�Other____
<br /> 4,_/
<br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING�S)
<br /> ' Di�n�ey,f �f Deptq � Set in oversize hole? Annular space initially grouted?
<br /> Property owner's mailing address it different than well location address indicated above iE- s f� .—
<br /> _ in.from_ to` �V ft. ,. ,Yes �lo j� �Yes [ �No [_'.Unknown
<br /> ��� ____in.from_ to ft. '�.__1 Yes `_No ,-.Yes '�,_�I No � ��Unknown
<br /> ` ,
<br /> _ _ in.from_ _ to. __ ft. ❑Yes ❑No [�Yes [j No � '';Unknown �
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � �
<br /> Well owner's mailing address if different than property owners address indicated above SCfeen from�_to._��� fl. Open Hole from_ _._ to_ ___fl.
<br /> OBSTRUCTIONS
<br /> �ods/Drop Pipe ��Check Vaive(s) _Debris �]Fill �/i N�o Obstruction
<br /> . �_
<br /> Type of Obstructians(Describe) ��N�� t ..G� � / ��?
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ��es �, �.No Describe_
<br /> FORMATION
<br /> PUMP
<br /> If not known,indicate estimated formation log from nearby well or boring. �, t� /�1
<br /> �: / ) "
<br /> � n. C�.� l�v` TYPe—.��L� (� U�'Y� • _ �
<br /> , - 'a
<br /> �emoved �Not Present ❑Other_
<br /> M�OD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: ��
<br /> o Annular Space Exists I Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
<br /> ` ._,_______in.from to ____ _tt. ❑Perforated '._-',Removed
<br /> .__ __in.from to _fL []Perforated [_)Removed
<br /> Type of Perforator
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? �._'.Yes `�No TN#_, _
<br /> �a GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �
<br /> g fV���`�'6/�-��b U/ ��� , � Y
<br /> Groutin Material__ _. m_ to ft._________ yards bags
<br /> _ irom_ to ft. yards bags
<br /> - ____,_ from____ to _ ft. yards bags e
<br /> OTHER WEILS AND BORINGS
<br /> - REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed.and unused well or boring on property? ',r.�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
<br /> RECEIVEDis Vue to the best of my knowledge.
<br /> . � t)an Stodola E�ell Drillini; Cc�,. inc. Ih�1
<br /> � d
<br /> �i� � .b __ -_'_.__._.'_
<br /> 6 � � - � � .Licensee Busines�Name _.. ^ �,,� License or Registration No.
<br /> ._..�-'� � 'Y' .
<br /> % .' �
<br /> CITY OF ORONO � �� ,-���y,�!� �` ��-- f �f�
<br /> -' ��-� _
<br /> rt� ed epresentative Signatur�' Certilied Rep.No. Date
<br /> , ..,.
<br /> " LOCAL COPY H � ^ �- � � ��� � '�Y~J �
<br /> � ° / -- -- -- - - - --- -..
<br /> w.°����L 9 9 __..----- —
<br /> Name ol Person Sealin Well or Bonn
<br /> HE-01434-14 IC#140-0423 ��� Sn3a
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