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MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring +f ����� � <br /> �- WELLOR BORING LOCATION yyELL AND BORING SEALING RECORD Sealing No. �H_y <br /> Counry Name Minnesota Unique Well No. r — � <br /> M�nnesota Statutes.Chapter 1031 or W-series No. I <br /> ?Henne in M1.�.d�„�«k��, �- <br /> Township Name Township No. Range No. Section No. Fraction�sm.-►Ig.) Date Sealed Date Well or Bormg Constructetl . <br /> Orono II7 23 07 43�-4�31'� p ., <br /> Numencal Street Address or Fire Number and CRy of Well or Bonng LocaGon e�/.�r A� � <br /> 4 36 5 N Sho re �t� ��0�� 5 J 3 V Y Depth Before Sealing fCJ tt Original Depih /� ft <br /> Show exact Iceation of v.•ell or boring Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid wrth"X`. locanon, showing property Single Aywfer � MultiaquAer <br /> 31ine5,roads,a d ildings. <br /> . ry .� _ ,,�� 1,.. � ���, , yVElUBORING �Measuretl ❑ Eshmated <br /> � ���Water Supply Well ❑Monit.Well / <br /> s ❑ Env.Bore Hole ❑Other _ _�ft. �below ❑ above land surface <br /> �-- � W --�- -i-- -i-- --i— E . ..___.....__..__. CASING TYPE(S) <br /> --�- -�-- --;-- --�— � �Steel � Plastic �Tile �Other <br /> }1 mi <br /> - —`- -�-- -�-- --1-- � _...�_. \� CASING(S) <br /> � Dlamete� Depth t Set in oversize hole? Annular space initially grouted? . <br /> S ,/� /_ <br /> �i mxe� �� - � in.irom S.� to_�L.2 ft. ❑ Yes �lo ❑ Yes ❑No ❑ Unknown <br /> b <br /> PROPERTV OWNER'S NAME '- in.from to R. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> Pioperty owner's mailing adtlress if di8erent than well location address indlcaied above. in.from to fl. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> i83b2 Bear Pa�h Ttl SCREEWOPENHOLE ! <br /> �tt�T �/� r <br /> Fden Pratt�� i�ti 5 5 347 Screen from �� ro J� ft Open Hole from ro R. <br /> OBSTAUCTIONS <br /> WELL OWNER'S NAME �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction <br /> Well owners meilirg eAdress if dillerent than property owner's adtlress indicated above. TypB of ObSINCtions(DeSCribB) �""�"' ��G�- ) 7'" !�'GJ�/�/"�/C S <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP <br /> f ; <br /> TYPe <br /> GEOLOOICAL MATERIAL- COLOR� HARDNESS OF FROM TO � Removed �ot Present ❑ Other <br /> FORMATION <br /> N rat krawn,indicate estimated fortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> d r i f t � 70 3�o Annular Space Exists <br /> O Annular space grouted with tremie pipe <br /> ❑Casing PeAoration/Removal <br /> in.from to R. ❑ PeAorated ❑ Removed <br /> in.from to tt. ❑ Perforated ❑ Removed <br /> Type of pertoralor <br /> ❑ otner <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Groutlng Material N��i ��"����,.L to��,L fl. yards �_ bags <br /> from to ft. yards bags <br /> from to ft. yards begs <br /> from to__ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property7 ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOH CERTIFICATION <br /> This well or boring was sealed in eccordance wilh Minnesota Fules,Chapter 4725. The infortnation contained in this report is <br /> true to Me best of my knowledge. <br /> Don Stodoia We21 Dril2ing Co. , Znc. 27I72 <br /> Contractor Business Name License a Registrafion I':o. <br /> - .--'"� 8-31-0 I <br /> rized R resentative Signature �- Dare <br /> .��tEl At1�UI130�! <br /> H ������ Name ol Persan Sealing We0 a Bonng <br /> LOI.'AL C.OP`Y <br />� <br />