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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Mi a Well n g <br /> County Name <br /> WELL AND BORING SEALING RECORD Seal No. ' N . H 12 7 9 9 3 <br /> lenneizi Minnesota Statutes,Chapter 1031 or W- <br /> �->� ue „,,tO% <br /> (leave tel" k if not know <br /> Township Name Township No. Range No. Section No. Fraction(sm.i Ig.) Date Sealed Date Wel Qr'ring Constructed <br /> Orono 117 23 02 >6 >6 u 24 c:fe 57 ,d• <br /> Numerical Street Address or Fire Number and City of Well or_Boring Location / / <br /> 15 Orono Orchard Road .N.)Orono, N'-j pth Before Sealing z ft. Original Depth z ft. <br /> Show exact location of well or boring etch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with'X'. I tion, showing property Jp�j`["ingle Aquifer 0 Multiaquifer <br /> lines, ,and buildings. <br /> N ,;? WELUBORINGeasured <br /> 90 . CI Estimated <br /> Water Supply Well ❑Montt.Well e <br /> --t---+---1----+—I : 1 \\, l ❑ Env.Bore Hole ❑Other fl ft. <beiow 0 above land surface <br /> W- Iiiii <br /> I I I E CASING TYPE(S) <br /> --1----t----1----i--- I + / i <br /> I t I ! u mem Steel ❑Plastic ❑Tile 0 Other <br /> --+---1---4----1-- 1 i CASING <br /> S <br /> L. ,-,1,` ;. L. ,,s Diameter Depth 254 <br /> j�/ , Set in oversize hole? Annualar space initially grouted? <br /> �—i^' 11in.from to G T 0 ft. 0 Yes No 0 Yes ❑No ❑Unknown <br /> PROPERTY OWNER'SNAME James Farley in.from to ft. ❑Yes ❑No 0 Yes 0 No ❑Unknown <br /> Property owner's mailing address if different than well location address indicated above. - in.from to ft. ❑Yes 0 No El Yes ❑No ❑Unknown <br /> %Jerry Ahlstrom <br /> / SCREEWOPEN HOLE <br /> w/Roger Fazkddlin �/� / / <br /> - Realty Screen from to ft. Open Hole from 25/P: to 2 ft. <br /> 473-7000 OBSTRUCROWDEBRIS/FILL <br /> WELL OWNER'S NAME >f Obstruction 0 Debris 0 Fill 0 No Obstruction <br /> Well owner's mailing address If different than property owner's address indicated above. - Type of Obstruction/Debris/Fill 1 n/A,t�/t r <br /> f . U/•-7 f� <br /> Obstructlon/Debris/Fiil removed? ,(Yes 0 No <br /> PUMP <br /> Type SUI' Pump <br /> HARDNESS OFFROM TO '`Removed 0 Not Present ElOther <br /> GEOLOGICAL MATERIAL COLOR FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. )(No <br /> USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: - - <br /> ciir ) No Annular Space Exits <br /> (( �� �CJ' ❑ Annulerspace grouted with tremae pipe <br /> i -1...:— �`—� .-J'J 0 Casing Perforation/Removal <br /> /Rem oval <br /> t in.from W, ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> e <br /> Grouting Material A//-.LST .141 a/I'_ m ✓ to21?---2ft. yards bags <br /> from to ft. yards bags . <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEAUNG UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? 0 Yes <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained M this report is <br /> true to the best of my knowledge. <br /> DON STODOLA WELL DRILLING CO. , INC. 27172 <br /> Contractor Business NameLicense or Registration No. <br /> —Afl-6;----ei5c:AtIP//ee '!17:°;11PPP'4 <br /> Data <br /> LOCAL COPY H 12 7 9 9 3 Name of Person dealing well orBoring <br /> HE-01434-02 <br />