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WELL oR BORING LOCA71oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 119 2 9 2 <br /> County Name <br /> WELL AND BORING SEALING RECORD M nn'e9oNa Unique No. <br /> H't..'T2i14�li� Minnesota Statutes,Chapter 1031 or W-series No. <br /> (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 i i 7 24 7 ,� ,, ti �/23/9 i <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 1295 Elm�►oc�d p1Y£ Depth Before Sealing �� ft Original Depth g� ft. <br /> Show exact location of well or boring Sketch map ot well or boring ADUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". �� � location, showing property �Single Aquifer ❑ MWtiaquffer <br /> i � lines,roads,and buildings. <br /> N WELUBORING �]Measured ❑ Estimated <br /> _Y_ _ _ _l__ _l__ <br /> ' Water Supply Well ❑Monit.Well <br /> { � ❑ Env.Bore Hole ❑Other �0 <br /> � � ft. �below ❑ above land suAace <br /> : <br /> --i-- '�-- 'i-- --i-- ' : � k <br /> W � � E ` CASING TYPE(S) <br /> � � � � � � i..,,�. <br /> --�- -�-- -�-- -"'�-- Steel Plastic <br /> ❑ ❑Tile � Other <br /> u mi�e � <br /> --�- -�-- --i-- --�-- � -- CASING <br /> Diameter Depih Set in oversize hole? Annualar space initially grouted? <br /> S <br /> �—i m��e—�e _� in.from� to� ft. ❑ Yes $�No ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Properry owner's mailing address if ditterent than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> Screen from 7� to �� R. Open Hole from to R. <br /> OBSTRUCTIOWDEBRIS/FILL C�r(OF <br /> WELL OWNER'S NAME <br /> [[�Obstruction ❑ Debris ❑ Fill ❑ No Obstrudion � � <br /> ORON <br /> �� ' fl�`'„r',r--'- i <br /> � , <br /> Well owner's mailing address if different ihan properry owners address indicated above. Type of Obstruction/DebriS/Fill � � <br /> Obstruction/Debris/Fill removed? [][Yes ❑ No <br /> PUMP <br /> TYPB ��t �u�� � 3 1��7 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �'�emoved ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated fortnation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASI G AND BORE HOLE: <br /> n Q 0 OCNo Annular Space Exits <br /> citift v c� <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Pertoration/Removal <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> in.from to ft. ❑ Pertoreted ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material��r�13I1 t� from �� to 0 ft. yards L bags <br /> from to ft. yards bags <br /> from to R. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes �GNo <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in eccordance with Minnesota Rules,Chapter 4725. The infortnation contained in this report is <br /> true to the best of my knowledge. <br /> R.�.S. We:ll Uril2in� 27275 <br /> Contrador Business Name License or Regisfretion No. <br /> �,�' t � �,'"�_.-. 1 � <br /> i ,.._�_-,": �:� ^!. �'l�- � 1, <br /> � � _ —� �/,��1/ � <br /> Authorized Representative Signafure Date <br /> James Lea <br /> LOCAL COPY H 119 2 9 2 Name ol Person Sealing WeII or Boring <br /> HE-01434-02 10/95R <br />