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Minnesota 44813Welland Boring <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> BenneMinnesota Statutes.Chapter 1031 or W-series No. <br /> pin0,........ <br /> Township Name Township No. Range No. Section No. Fraction(sm. .lg.) Date Sealed Approximate Date Well <br /> Orono 44�p 8g� 2.3 35 pp� /4 /5 CCT c3 or Boring Constructed <br /> L�;7 �f <br /> Numerical Street Address or Fire Number and City of Well or Boring Location � <br /> 1005 Old �tgLake Depth Before Sealing dra ft. Original Depth /[iy ft <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level Fi.e1iccurate <br /> in section grid with"X-. location.showing property lines. <br /> y roads.and buil in s. ❑Approximate <br /> ` Single Aquifer 0 Multiaquifer !`' R. below above land surface <br /> t ` <br /> "t L <br /> W I E t ‘_ <br /> -i • <br /> CASING TYPE <br /> S <br /> ra: <br /> r-' h mile <br /> feel 0 Plastic 0 Tile 0 Other <br /> ...q....1 e t <br /> g't Screen from ` to ft. Open Hole from to ft. <br /> S ,t ' ,../J4 <br /> N--1 mile-awl OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME ❑Obstruction Xpebris 0 Fill <br /> Nancy Samuels-Hoyt 2 of 2 dyne df A R4e- <br /> Type of debris/obstruction +r <br /> Mailing Address if different than properly address indicated above. <br /> Obstruction/Debris/Fill removed?likes 0 No <br /> 72 niversid® AVe PUMP <br /> } vers de, CT 06878 0 Removed lot Present 0 Other <br /> ate. ilkC CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring. , i / <br /> l�i.i ^ `� in.from C> to ft. 0 Yes ,/Jo 0 Yes 0 No 0 Unknown <br /> ll�i. �j W in.from to _ ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> in.from to ft. ❑Yes 0 No 0 Yes 0 No 0 Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE pArlo Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> 0 Casing Perforation/Removal <br /> r AN 3 1994 <br /> in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> _.. Type of perforator <br /> I` _. l'' ❑Other <br /> GROUTING MATERIAL <br /> A y <br /> Grouting material A/CA` cx -fel 0 to &te <br /> ft. yards _bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> Grouted 2" well 68' deep from to ft. yards bags <br /> ,..abs4L cement UNSEALED WELLS AND BORINGS <br /> Jbentonite Other unsealed well or boring on property? 0 Yes o <br /> 2men orf rig & cement grout pump 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 tothe best of my knowledge. Drilling �+� Inc. e� �{ <br /> Don S _. a Well Co., 27172 <br /> Contractor Business me License or Registration No... � 10-] 3 <br /> Authorized Representative Signature Date <br /> Jim Antonson <br /> LOCAL COPY H 4 4 813 •~ <br /> Name of Person Sealing Well or Boring <br />