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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 5 3 3�7 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnleso a�Unique Well No. <br /> ��� i� Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank i�not knownf <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 3 26 3�A Z(� f.�C'T� o t.., <br /> . <br /> GPS Latitude degrees minutes seconds Depth Before Sealing � 7 ft. Original Depth k. <br /> LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ��Multiaquifer <br /> WELUBORING �Measured �]Estimated Date Measured__ ._ - <br /> ,� �Water-Supply Well ❑Monit.Well � <br /> ' Show exact location o �ell or boring Sketch map of well or boring . <br /> in section grid with"X" location,showing properry I�Env.Bore Hole ❑Other �Q ft. ;�ibelow ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> ' --'---- �-----'—---'-- � �Ste <br /> ; j j j j �. � el ❑Plastic ❑Tile �. th <br /> ' ]O er <br /> � --�--- --�--- ---�-----'-- WELLHEAD COMPLETION <br /> W � � � � E I <br /> , � � � � Outside: ❑Well House ❑At Grade Inside: �asement Offset � <br /> 'h Miie ❑Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> - .--- --,--- -�- --:- 1 <br /> ❑Well Pit ❑Buried <br /> S ❑Other <br /> I , qt <br /> �1 Mile� 1 �-- 1�, � �,��-q�,. ❑Othe� <br /> � �.>`'._ 1. a.,.. �-4. <br /> PROPERTY OWN R'$NAME/COMPANY NAME CASING(S) <br /> I�tichae�1Stachia Fe Diameter� � Depth � Set in oversize hole? Annular space initially grouted? <br /> Properry owners mailing address if difterent Ihan well location address indicated above � � �—, <br /> in.from� b�R ,�Yes �No ❑Yes ❑No (_]Unknown <br /> in.from to R (J Yes jJ No ❑Yes ❑No ❑Unknown '�� <br /> � <br /> in.from fo ft. ❑Yes ❑No j]Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE f <br /> r � <br /> Well owner's maiiing address if different than property owner's address indicated above Screen from��to��ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> i <br /> ❑Rods/Drop Pipe �J Check Valve(s) ❑Debris ❑Fill �j No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> It not known.indicate esfimated formation log from nearby well or boring. <br /> /-t, � Type <br /> � ❑Removed �Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists I J Annular Space Grouted with Tremie Pipe �Casing Perforation/Removal <br /> in.from to fl. ❑Perforated �]Removed <br /> i <br /> in.from to ___ft. ❑Perforated '�Removed <br /> � Type of Perforator_ __,__ _ _ <br /> ❑Other <br /> � <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> 4 t � <br /> Grouting Material N��/ C�dJ��iC!/from_�_,_ to��__ ft. yards� bags <br /> from to ft. yards bags <br /> from to ft._ _ yards _ bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes ��. o 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 /> is true to the best of my knowledge. <br /> Dc� Stodala taell Drillin� Co, Inc. 169I <br /> Contractor Business ame License or Registration No. <br /> i <br /> ��'`J� � C�, G{r� <br /> rese tative Signatuie Certilied Rep.No. Date <br /> J=J,�/\,/Y'.Nti���.QJ��Y`�-- <br /> LOCAL COPY H 2 5 3 3 8 7 y� <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-09 IC�140-0423 ,. s/osR <br />