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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 2 71�2 3
� WELL OR BORING LOCATION Sealing No. H
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
�� Minnesota Statutes,Chapter 103[ or W-series No.
(Leave blank�il no�knownJ
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed �p Date Well or Boring Constructed
�O�O 11lr Z� Zl '/. '/=l�R/< �g'• Z�f LWS
Latitude degrees minutes seconds ��i
GPS Depth Before Sealing ___ ft. Original Depth ft.
LOCATION: Longitude degrees___ minutes seconds
�UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer [�Multiaquifer p/�C/Op
'j585 $b4Y� �• �� WELL/BORING �Measured []Estimated Date Measured � __-� �
` �Water-Supply Well []Monit.Well
Show exact location of well or borin � Sketch map of well or boring 6�
in section grid with"X" location,showing properry ❑Env.Bore Hole �]Other _ _._ft. �below �above land surface
N � lines,roads,and buildings. CASING TYPE(S)
'- --'--- —'--- ---`— ---'—
�� �Steel ❑Plastic ��.]Tile I_�Other _
�� -'--- � —`-- �
r " ; --;--- - ; ---;-- � WELLHEAD COMPLETION
W � � � � E � �'��.
��� ' � � � -; Outside: ❑Well House ❑At Grade Inside: n Basement Offset �
--;----.-----�-- --:- T
.
�. � , 'h Miie -...� � ❑Buried �l!Well Pit ��
; � Pitless Adapter/Unit ..
' --�-- --S : .- ..»
� ❑Well Pit � �Buried
�Other
�1 Mile� . ❑Other
P PERT R'�Ntq7�1E}/C�OMPANY NAME � CASING(S)
����"`^�~ Diamgter n Depth��C Set in oversize hole? Annular space initially grouted?
Property ownec m� ailinq addr�iflerent than well location address indicated above , jn.from V to � ft. �Yes U No [�Yes �;J No ❑Unknown
1585 .�hsd &1
Orono, t� 55331 in.from to n.
❑Yes ❑No �]Yes ❑No ❑Unknown
in.irom __. to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WEL� L OWf�E�R'SQA E/C tArrNY NAME SCREEN/OPEN HOLE
U�fS�ltl .�c
Well owner's mailing address if different ihan property owners address indicated above SCfeen from �� to 331 ft. Open Hole ffom to ft.
OBSTRUCTIONS
❑Rods/Drop Pipe ❑Check Valve(s) !_j Debris i �Fill �No Obstruction
Type of Obshuctions(Describe) __
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe
FORMATION
PUMP
��� If not known,indicate estimated formation log from nearby well or boring. �� _
Type
�Removed ��_]Not Present n Other _.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: t
�No Annular Space Exists �_I Annular Space Grouted with Tremie Pipe �!Casing Perforation/Removal
in.from to ft. ❑Perforated n Removed
in.from to ft. ❑Perforated []Removed
Type of Perforator
[�Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material��� C�� from O to 331 ft. yards �v bags
from ro R. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes �No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
is true to the best of my knowledge.
Steveae Drilling i B�r. Svc. iac. 2255
Licensee Business Name .; ��� License or Registration No. �,
r
�
, � 555 8/18l/S k
' ' Certilied Representative Signature Certified Rep.No. Date
_ �cc��;;o-�; H 271423 ?ii Stevens
Name ol Person Sealing Well or Boring
iE-01434-10 IC#140-0423 5/ma
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