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MINNESOTA DEPARTMENT OF HEALTH M�nnesota Well and Bor�ng ` <br /> MIELL OR BORING LOCATION Sealing No. i H 14 6 0 6 5 <br /> Counry Name H��n� �� WELL AND BORING SEALING RECORD Minnesota Unique No. ---- <br /> � Mmnesota Statutes,Chapter 1031 or W-series No. � <br /> ILeave dank�1 rwt known) <br /> Township Name Township No. Range No. Sec6on No. Fraction(sm.�s Ig.) Date Sealed Date Well or Boring Constnictetl <br /> ro�o 117 23 08 " ` � RJ �}r'? <br /> Numerical Street Address or Fire Number and Ciry of Well or Bonng Lowtion � � <br /> IJ�� ��r�.�l L�r� Drive Orono, � DepthBeforeSealmg N. OrigmalDepth �it. <br /> Show e:ad locatio�of w•ell or boring l� Sketch map of well or bonng A�UIFER�S) STATIC WATER LEVEL <br /> in section gnd with'X'. location, showing property Smgle Aywter � Muqiaqwfer <br /> ` } lines,roads,and buildmgs. <br /> N i � WELI/BORING Measured ❑ Estimated <br /> ' "� - Water Supply Well ❑Monit.Well �+r / <br /> - - - - - — - -- �. <br /> � � ❑ Env.Bore Hole ❑Other _ _� � fl. �]pelpw ❑abovg la�d suAace <br /> t <br /> W —�- -i-- -i-- --i-- E � f CASING TYPE(S) <br /> � � � � ` <br /> -r- -�-- -i-- --�-- � :�—��, �Steel ❑Plastic ❑Tile �Other <br /> .o <br /> u m�ie . � � <br /> , , � � � : - .___...._-. CASING <br /> --�- -�-- -i-- --i-- . : � <br /> �"'--�� Diamet/r� Depth f Set in overslze ho1e7 Arrriaiar space Krtielly grouled7 <br /> ' g 1 � t <br /> �_r,,,�,—�. �—- � m.irom� ro �� R. ❑ves �No ❑ves ❑No ❑u�rawn <br /> PROPERTV OWNEH'S NAME in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑UNcnown <br /> Mar ar�t Pelto�ra <br /> Property owner's mailirg address if diflerent than well IocaUon address indicated above. in.from to fl. ❑ Yes ❑NO ❑Yes Q No ❑UnWlOwn <br /> SCREEWOPEN HOLE <br /> ���f � f <br /> Screen from�`�to� fl. Open Hole from b 11. <br /> OBSTRUCTIONS <br /> YVELL ONMER'S NAME Rods/Dr Pi <br /> oo ve ❑cn�vanrecs) ❑��5 ❑ F�n ❑nio oo�� <br /> Well ownefs meilirg address N ditterent than propeAy owner's address inAicateA above. Type of ObslruCtions(DeSCtibe) �,L iF'�,Y�,1 /_/.��Cl� /— /`����C/�� <br /> Obstructions removed? Yes ❑No Describe <br /> PUMP <br /> Type ST��f. �Uml' <br /> fiEOlO(i1CAL MATERIAL COIOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> M na1 kravm,indica�e estimeted lortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINCS,OR CA,��MK'AND BORE HOLE: <br /> ...1 . t / ., No Annular Space Exits <br /> ; fi ,.� r 1 <br /> __ ❑ Annular space grouled wiM tremie pipe <br /> ❑ Casing PeAaataNRemoval <br /> in.from to fl. ❑ PeAorabd ❑ Renqred <br /> in.from to fL ❑ Pbrbrabd ❑ Rertwr'ed - <br /> Type of pertorata <br /> ❑ Otl�er <br /> GROUTING MATERIAL(S) <br /> �3n ',�T �� <br /> Grouting Material N�...I����//��'�lrom � ro R. ya�ds� bags <br /> frOm to R. Yards baps <br /> rr«o m a ya�as e.gs <br /> nom m a ra�es wyc <br /> REYARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Olher unsealed and unused well or boring on propertyl ❑Yes No How ma�� <br /> LICENSED OR RE('a1STERED CONTAACTOR CERTIFICATION <br /> This well or boring was sealed in accordence wilh Minnesorta Rules.Chapter 4725. The irom�etion oor�nad n tlrs iaport e <br /> tn,e ro me test a my know�edge. - <br /> DUN STQDOLA WELL DRILLING CO. , INC. 27172 <br /> Contractw Business Name i" �iosrrsr or Repstwon r:o. <br /> r• �,. �,;` � !'� <br /> A epresentatnre SigneNre' " Q�M <br /> x ,�` ..�: .,� <br /> LOCAL COPY H 1,4�iJ�S ��a P���W����e <br /> HE-01�34-03 2/97 R <br />