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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 'I 281777 <br /> Sealing o <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota Well NO. <br /> Minnesota Statutes,Chapter 103 or W-series No. <br /> afflWin (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 33 JW 9 Ju 09 <br /> •'OpS Latitude degrees minutes / } <br /> _ seconds Depth Before Sealing F ♦ , ft. Original Depth tt. <br /> LOCATION: Longitude degrees__ minutes_ seconds IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer ,,��// 51W M <br /> FEnv. <br /> ORING I�'�Qeasured ❑Estimated Date Measured <br /> 405 Old Crystal Bay Rd N ,-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or bin section grid with"X." location,showing prope Bore Hole ❑Other /27 ft. [below ❑above land surface <br /> N lines,roa , d buildin CASING TYPE(S) <br /> [Reel ❑Plastic !—'Tile ❑Other <br /> --"--- -----'-- -- ELLHEAD COMPLETION <br /> , T <br /> W EI <br /> Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> h Mil ess Adapter/Unit <br /> ❑Buried L1 Well Pit <br /> dl <br /> T -- - L1 Buried <br /> S ❑Well Pit <br /> ❑ L1 Other <br /> Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME ! CASING(S) <br /> Smsu Diam e`0 0 t Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing a ress different t an we location address indicated above AV in.from V to/&7ft. ❑Yes Ao L]Yes ❑No E]Unknown <br /> 251 Starkey St in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> St Paul, Mht 55107 <br /> n.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE I t , - <br /> Well owner's mailing address if different than property owner's address indicated above Screen from /&7 to / A71 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> .r• <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS <br /> ARDNE ONR FROM TO Obstructions removed? es E]No Describe FORMI <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> U � Type �p,jl- [1/�1.� <br /> Removed F1 Not.PresInt ❑Other <br /> OW <br /> ,M��ETTH�OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> levo Annular Space Exists L1 Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> FF in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material m 0 to n It yards—/V bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes EX 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 /> is true to the best of my knowledge. <br /> I <br /> Don St"In Well Drilling Co., Inc• 16% <br /> Licensee Business a License or Registration No. <br /> erti dere ati a gna r Certified Rep.No. Date <br /> LOCAL COPY H 28177 <br /> Name of Person Sealing Well or Boring <br /> HE-01434-11 ICn 140-0423 2/08R <br />