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� MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. H � � ���� � <br /> County Name Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 103I or W-series No. <br /> r7enna=�in «ea�a b�a�k,,�o,u�ow�, <br /> r Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Orona 117 23 17 *3'� !�7 tJ�l Z !� / <br /> . ; <br /> GPS Latitude__,_ degrees__ minutes seconds Depth Before Sealing 2�� ft. Original Depth ft. <br /> " LOCATION: Longitude___ degrees.__ minutes seconds <br /> �UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer �]Multiaquifer .�n ��- j <br /> 1h�d5 .�y�!� (�3 T�C� !����fl S��C�� W VBORING �Measured [j Estimated Date Measured J�"�m� ,�/'�' <br /> � \'�� �Water-Supply Well �]Monit.Well j <br /> Show exact location of well or boring Sketch map of well or b ing- � <br /> in section grid with"X" location,showing prope y . ❑Env.Bore Hole ❑Other _ ��__ft. �below ❑above land surface <br /> N lines,roads,and buildin s. CASINGTYPE(S) <br /> �� -'--- --'--- '--'---'-- <br /> i � �Steel ',�Piastic � I Tile �I Other_ . <br /> � � , � , . <br /> --'�----'--- ---`-----'-- •WELLHEAD COMPLETION <br /> W ; : ; ; ET x <br /> , <br /> � � � � - ' ,9ptside: ❑Well House ❑At Grade Inside: ❑Basement Offset b <br /> -- � <br /> 'h Mile t I�L ❑Buried ❑Well Pit � <br /> i Q f . ��Pitless Adapter/Unit <br /> 3 1 ' ❑Well Pit ❑Buried <br /> ; ; S ; ; +>.✓ ,. ❑Other <br /> �--1 Mile� ' ��f ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> �[� ,__ Diam t�� � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address it ditferent than well location address indicated above �"'�in.ffOm� to ����ft. ❑Ye5 �No 'i_ �Yes ❑No ��Unknown <br /> in.from to ft. ❑Yes ��No '��._ �Yes iJ No �-;Unknown <br /> in.from to ft. �Yes ��No �r]Yes ❑No �f Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE - <br /> / /�I <br /> Well owner's mailing address if ditterent than property owner's address indicated above Screen from �� to 27(!J ft. Open Hole from to .____ft. <br /> a <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris �]Fill ❑No Obstruction <br /> Type of Obstructions(Describe�lU�(J`�C I-�� ¢ ��/1')� _____ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM 70 Obstructions removed? �Yes []No Describe E <br /> FORMATION <br /> PUMP <br /> ' If not known,indicate estimated formation log from nearby well or boring. �Ce n � � <br /> _�. � ;r,j TYPe�v M- _ �., <br /> ; ! �.9� „lr.� . :. <br /> -- Removed ����.Not Present ❑Other_ .� <br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ��.No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ',J Casing Perforation/Removal <br /> _in.from to ft �_]Perforated ❑Removed <br /> �� _in.from _to ft. ❑Perforated [_)Removed 4 <br /> Type of Perforator <br /> ❑Other_ _ <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> �' Grouting Material�/`�/ �J1*�...I�� trom U' to��R____ yards�.� bags <br /> i <br /> - � _ from to ft. yards bags <br /> � from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> a REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on properry? ��J Yes No 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 /> RECEIVEDis true to the best of my knowledge. <br /> � stc�cl�la taeli ncii2in� Cca,. znc. 1�5q1 <br /> - ��f� Rj � �`)O�� Licensee Busines N e License or Registration No. <br /> lJ L � <br /> C�N� ��, � �f =J . �� <br /> F ORONO ertilieA epresentative Signature Certilied Rep.No. Date <br /> '.,I � .� � r ..��,,,%'," ���; �-.�.,3.;v '-�/ <br /> I.00AL COPV � �j � ��7 __ _ 9 _�9' __-- - <br /> Name of Person Sealin Well or 8 in <br /> HE-01434-13 IC#140-0423 � 5/72R <br />