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WELL OR BORING�OCA71oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �2 6 5 9 2 <br /> WELL AND BORING SEALING RECORD Sealing No. <br /> Counry Name Minnesota Unique No. <br /> ��enne�in Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank it not known) <br /> Township Name Townshi No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono O�7 23 07 , ,, ,, � �.� � <br /> Numerical Street Address ir Number and City ot Well or Boring Location � , <br /> 2 � <br /> 92 5 F or�s t �rr$:� Lane �r�n0 Depth Before Sealing �.�� ft. Original Depth �_.i� R. <br /> Show exact location of well or boring S�� Sketch of well or boring IFER(S) STATIC WATER LEVEL <br /> in section grid with"X". loc�!(i, slt`owing property Single Aquifer ❑ Multiaquifer <br /> N �s,roa ,and buildings. <br /> WELUBORING �Measured ❑ Estimated <br /> ' ' ' � Water Supply Well ❑Monit.Well /� � <br /> _ _ _Y_ _1__ __l__ �( <br /> t <br /> �� � ❑ Env.Bore Hole ❑Other ft. �below ❑ above land surface <br /> ,s <br /> --�- -i-- -i-- --i-- <br /> W E �{, � CASING TYPE(S) <br /> i <br /> � � <br /> � � i � � �\, <br /> --�- --�- -�-- --�-- - �.� Steel ❑ Plastic �Tile �Other <br /> ' ' I ' ;G mile � .y ,. <br /> � � � � ` � CASING <br /> ---- -�-- -�-- --�-- , e ryl .\,.. <br /> 1 / DiameteJr Depth � Set in oversize hole? Annualar space initially grouted? <br /> LL"" S / J �f-, � �f� ��,,----JJ <br /> p�i mae� `` �7 in.from i� to�5.,� R. ❑ Yes �No ❑Yes ❑No ❑ Unknown <br /> I <br /> PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> Len .iane Adass �72-3519 <br /> Properry ownefs mailing address B diHerent than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> �C��YU SCREEWOPEN HOLE <br /> i <br /> ,�' / � �� <br /> Screen from�_to fl. Open Hole from to ft. <br /> -p�;-' OBSTRUCTIOWDEBRIS/FILL <br /> WELL OWNER'S NAME �� �� '�- ❑ Obstruction ❑ Debris ❑ Fill�No Obstruction <br /> .n' <br /> Well owner's mailing address if ditterent�t��pro� rty wn�ds ress indicated above. Type of ObstructioNDebris/Fill <br /> �� � <br /> ObsiructioNDebris/Fill removed? ❑ Yes ❑ No <br /> -` ._ - • � PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate es6mated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exits <br /> — � ..� !:�. <br /> } ❑ Annular space grouted with tremie pipe <br /> _J ❑ Casing PerforatioNRemoval <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> � <br /> Grouting Matena �"`�r %<ry�� � l �� � / / <br /> V�"�'� N from � to�.e_G� tt. yards �L— bags <br /> from to tt. yards bags <br /> from to ft. 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 �No <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 is <br /> true to the best of my knowledge. <br /> Don Stodols �Iell Urillin� eo. , Inc. 2717j2 <br /> Contrador Business Name License or Regishation No. <br /> ..r' r��' l-,;�'� `+ �" �,r�-, .f'� /�C✓ `� � , <br /> ..% <br /> � uthonzed Representative Signature Date <br /> f � <br /> �`��,,,_" �..._ __•�-�,-��S�r�./�.�d'v'1. <br /> LOCAL COPY H 12 6 5 9 2 Name o/Person$qkling Well or Bonng <br /> HE-01434-02 10/95R <br />