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Minnesota Well and Boring 2 8 919 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> �o���Y Nam� WELL AND BORING SEALING RECORD M���esota u��q�e No. <br /> ����n Minnesota Statutes. Chapter 103! or W-series No. <br /> �Leave biank il noi known) <br /> Township Name Township No. Range No. Section No. Fraction(sm �Ig.) Date Sealed Approximate Date Well <br /> O�� ��� qg� � C{,'il�r 'Cy,r /' p'�C f(�� or Bonng Consiructed <br /> Ld Jw ,�K ���I O {7(7 <br /> Numencal Sireet Address or Fve Number and Cdy of Well or Boring Location <br /> ZJ�� F�x ,��',��t �}"(�� Depth Before Seahng ��� ft Onginal Depih ft. <br /> Show exact locahon of well or bonng Sketch map of well or boring Static Water Level �Accurate <br /> in sec�ion grid with��X��. loca�ion.showing property lines. <br /> N roads.and buildings. ❑Approximate <br /> i i i i <br /> _i_ _-_ ___ _i <br /> �Single Aquifer ❑Multiaquifer ft. X below above land surface <br /> i i i i <br /> _i_ _�_ _i_ _i_ CASING TYPE <br /> W i i i i E <br /> � � � � T <br /> _i_ _r_ _�- T ,�1t <br /> � � � � � LTSteel ❑Plastic ❑Tile ❑Other <br /> i.mile <br /> _i i i i_ � <br /> I I I I <br /> S Screen from to ft. Open Hole from to it. <br /> N--i mile--�I OBSTRUCTION/DEBRIS/PILL <br /> PROPERTY OWNER'S NAME ❑Obstruction ❑Debris ❑Fill <br /> 8ett stinson <br /> Type of debris/obstruction <br /> Maihng Address d differen�than property address indicated above. <br /> Obstruction/Debris/Fill removed? ❑Yes ❑No <br /> 134� fox Street PUMP <br /> Orono, ���N 55391 <br /> �Removed ❑Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log trom nearby well or boring. <br /> � in.from to ft. ❑Yes ❑No ❑Yes ❑No �Unknown <br /> in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists <br /> ❑Annular space grouted with iremie pipe <br /> ❑Casing Pertoration/Removal <br /> in.irom to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> Grouting material �at C�L�t from ��to �_ft. yards �_bags <br /> from to fl. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> House has been soid. from to fl yards bags <br /> 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 Minneso�a Rules,Chapter 4725.The inbrmation con�ained in this report is <br /> true to the best of my knowledge. <br /> Stevens Well Dril'ltn� Co. lnc. �7194 <br /> Contractor Business Name ' License or Registration No. <br /> �; s� .r,'����� '� 8/26./93 <br /> � 1�,�'�.�,.q..,,,� �„�;,� � <br /> Authorized Representative Signature � Date <br /> LOCAL COPY H 2 g 919 TQ� S'�Y@{1S <br /> Name ol Person Sealing Well oi Boring <br /> HE-01434-Ot � <br />