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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i ��O��� � <br /> WELL AND BORING SEALING RECORD Minnlesota Unique Well No. H <br /> County Name -- <br /> Aenn�pin Minnesota Stalutes,Chaptei�03� o�W-�eri�sNa �_ � <br /> Township Name Township No. Range No Section No. Fracuon�sm.�Ig.) Date Seaied Date Weu or Bonr�g Constructed <br /> - Orono 117 23 0$ �� �� � <br /> Numerical Street Atldress or Fire Numbei and Ciry of Well or 8oring�ocation � , <br /> 3fi25 t�� Sh�tB Lr • Orano, �. Depth Before Sealing ��� __R Oriqinal Depth __���___ h <br /> Show exad locah n of K�ell or boring Sketch map of well or bonng ApUIFER�S) STATIC WATER LEVEL <br /> � in section�ri it�"X'. IocaUon, showing property Single Aywfer � Multiaqwfer <br /> ( I�ne�,roads,and buildmgs. <br /> ry J��! � '+ ,J WELUBORING �vleasured ❑ Estimated <br /> � r <br /> ater Supply Well ❑Monit.Well /� i <br /> � ❑ Em.Bore Hole ❑Other _ Gr_�R �below ❑ above land surtace <br /> W -�- -i-' -i- --i- E CASING TYPE(S) <br /> � -�-- -�- --i-- --�- � �Steel ❑ Plastic �Tile � Other <br /> }�e milB �� <br /> `- -�-- -�-- --�-- � CASING(S) <br /> .,�� Diame er�` Depth � Set in oversize hole9 Annular space initially qrouted7 <br /> � S � l'�' � �l Ves �Jo ❑ Yes No Unknown <br /> t mae� q`�'" in.irom to R. ❑ ❑ � <br /> PROPERTY OWNER'S NAME in.irom �o R. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> ' 1 �•x 3 <br /> Property owner's mailing address ilmun�nrn man wen iocauun nuuinae mw�am�a..�.a,..�+,���' in.frOm t0 ft. ❑ �0S ❑NO ❑ �'e5 ❑NO ❑ UnknOwn <br /> ,•��� ?.� SCREEWOPEN HOLE <br /> =3fiP'��` £t!S �; � r <br /> Screen trom_�_to�� ft. Open Hole irom to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �Rods/Dro Pi e <br /> p p ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing aAAress if tliMerent than properry ownar's atltlress indicalad above. Typ6 Of Obstrudions(DeSCribe) -fA.//V�J� � /�a� � ��e'/l/- <br /> Obsiructions removed? �Yes ❑ No Describe <br /> . ._ - -- --- .. _.. PUMP "�} <br /> TYPQ a�C.l.�'� r+ IJ<-LJ! <br /> GEOLO(31CAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If rat krawn,indicate estimateA tormatbn loq hom nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BE7WEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �o Annular Space Exists <br /> Annular space grouted with tremie pipe <br /> ❑Casing PeAoration/Removal <br /> in.from ro tt. ❑ Perforated ❑ Removed <br /> in.irom to tt. ❑ Perforated ❑ Removed <br /> - Type of perforaror <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> ,t.l�/�` C'�`,'���L ' <br /> Grouting Material - to.�,�Z R. yards � bags <br /> from to fl. yards bags <br /> irom ro R. yards bags <br /> from to__ ft. yaids bags <br /> REMARKS,SOURCE Of DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes o 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 /> '„ _ _ . .:; t80N STOl?QLA WBLL DRILLING Ct?. , INC. 271'72 <br /> Confracror Busine eme A . Cicense or Registretion I'Jo. <br /> '3` � .} -'. � jy-! d �' ii"�f��'�� <br /> / <br /> th0`r!i epresentative Signeture' Dete <br /> ;�:',� t�r tJF30i"�'C� <br /> �7in� A�ttonsoQ <br /> A^���� Name al Person Sealing Well or Bonng <br /> LOCAL COPY H G S� <br />