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STATE OF NINNESOTA OEPARTNENT OF HEALTH <br />NELL RECORDr <br />I. lOMTIM or «u <br />CMMiyiiMt fjgnnepin <br />nrnnn <br />To«ilMp <br />117N r <br />MINNESOTA UNIQUE NELL NO. <br />OtDvt IlMl If ml kiMM) <br />Unm Nuabtr <br />C <br />Of <br />23V7 “ <br />Stctloo No.Fficiloo <br />k S9f k <br />s;v m ME <br />NuMflcil Strtol ANNrttt ooN CUy of Moll locaklofi or Olatioct fro« Noad <br />lotortictloii <br />940 South Brown Road,Orono 55356 <br />Show tiacl localloo of noil <br />(In faction |r1d »ICN *1*) <br />N <br />SkotcN mp of noli location <br />4. MCU OCFTN (C0«NltUd) <br />ft. <br />120 <br />OtU Mtl.4 <br />06/19/91 <br />S. MIILIM ICTNOO (If I mm) <br />iQ Cakl. U.I ^ ■iMrM IQ Orl«M l(Q Bwf <br />••Ury Cl JklM Q fMtr toftr <br />. L .a <br />m • • <br />•r • <br />. • <br />1 <br />1 <br />f <br />1 <br />a <br />0 <br />a <br />1 <br />0 <br />« <br />• k * <br />• <br />» <br />• r <br />• <br />1 <br />• . • <br />1 <br />1 <br />> • » . <br />1 <br />• • A« • <br />4 <br />. <br />« .0. . <br />0 <br />• .i.. <br />0 <br />a <br />S <br />I miU <br />r <br />2. Mofcin owia's <br />Carol Senn <br />Nitlinf Addrttt If difforont than <br />proptrty addrtti Indicated above <br />3. <br />HOiONCSS OF <br />COiOt FOflMATION FNON TO <br />If not knoMi, Indicate feraatlon lof froa new veil or nearby netl. <br />FONNNTIOM LOO <br />4. OISTiUCTlOit <br />Mall obatmeudQ Vet Q No <br />Obitnictlent rtvad Q Tea Q He If obttmctlena cannot be <br />ntvad, contact NON <br />before aoalinf. <br />7. USI <br />iQ OOMltlC <3 ItoOf tOffNf C] ^ <br />2Q irrlfotlon fQFobllc lQ Indoatry <br />3Q Teat Moll G ibRiUfool UO CoMrclal <br />7Q Air Coodltlonlof lOH ‘ V . ^ "w- <br />I. asIM(S) <br />iQllacfc ^Tbroadod iQ <br />^Q Fiaatic iSQ SUlnloii Stool <br />3 In. U <br />In. to <br />,ft. <br />ft. <br />f. scara <br />QSc well free <br />□ Ooon Nolo free <br />ft. U <br />ft. u <br />ft. <br />ft. <br />10. STATIC NATfl LCm <br />__31]____□•tew 06/19/91 <br />land aorfaco OaU NMonrod <br />IS. KNAIU. CLCVATIOi, SOUNCC OF DATA - aSINfiS ACNOTIO. aSINOS FCRFOAATID. CTC. <br />11. MCLUCAO CQNFUTION <br />IQ Fitloaa Adaour <br />43 Oifoeant offaet <br />12. gNMlTlHO IHFOMATION <br />iQ Neat Caaont 4D Otntenito 43 <br />Sroyt aaterlal 4 b^QS fry 0 tJ»20 ft. cu. yda * ' <br />13. NUNIST SOUNCCS of CONTANlNATIOi <br />_ _ feet _ _ _ _ _direction <br />doll diainfocted before aealinf? Q Tea <br />14 FUNF Q Ne««od □ Mot Freaont <br />lype: O Subaoralblo Q Tvrbino 43 Aoclprocatlof <br />G Jet 43 Cl <br />IS. UISTINO MILLS (Fleeao afcetcb locetloea of abandoned and <br />active nella In reairba aoctlen or on back.) <br />Other unvaed Ml 1(a) on property? O ^*4 BD Ho <br />Abandoned: Q Feraanent Q Teeporary Q Not aea«od <br />17. MATCH MILL CONTNACTONS CCITIFlUTlOi <br />This well waa sealed under ay jurladictlon and thia report <br />Is true to the bast of ny knowledfo and belief. <br />Stevens Well Drilling 27194 <br />ICUl maOOWJ UCU neon (ll»y W Ultf for Oroport; Trimftr) <br />I fits nn <br />6248 ‘"'RjB;35 *n itest License No. <br />AddraaaMa <br />Slpned 1 <br />iaple Pl^y,55359 <br />Dick Stevens <br />06A9/91 <br />b6/i9/l#l <br />Naan of Driller <br />• S1