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�" <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ; 13 4 9 3 6� <br /> WELL AND BORING SEALING RECORD Sealing No H <br /> County Name Minnesota Unique No. -- <br /> Minnesota Statutes,Chapter 1031 or W-series No, � <br /> ILeave blank it not known7 <br /> Township Name Township No. Range No. Section No. Fraction�sm.-►Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 1I8 23 3b 3�-Ot1 ' � �i <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location q �' ! <br /> 4 M wo d �d 4rono Depth Before Sealing �G� k Original Depth � <br /> Show exact location of well or boring ��39�ketch map of well or bonng ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". cation, showing property Single Ayuifer ❑ Mul6aquiter <br /> N �� lines,road and Id ngs. <br /> �.���.1.���-v�- -.�:."� WELUBORING Measured ❑ Estimated <br /> � `�—' Water Supply Well ❑Monit.Well M � <br /> -- - - -- -- -- --i-- � f��1 <br /> pa �� ❑ Ern.Bore Hole ❑Other ___ ""'-'� ft. ,�below ❑ above land surface <br /> W --'r -i— -i— --i— E _. ��1 ,.,,y. CASING TYPE�S) <br /> � <br /> � � � <br /> � � � <br /> -;— -�-- -;-- --;-- �Steel � Plastic �Tile � Other <br /> � � ' � �mne <br /> ' ' ' ' � CASING <br /> ---- -�-- -�-- --1- �_ <br /> .._..___.. <br /> Diameter f Depth � Set m oversize hole? Annualar space iNtially grouted? <br /> S ! <br /> �r mae� � ^Y y '� � in.irom� to�fl. ❑ Yes �No ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> s <br /> Property owner's mailing address�t diHerent than well loca6on address indicated above. in.from to tt. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> /�/�1 / <br /> Screen from_�L to�� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction <br /> Well owner's mailing address if ditterent than property owners address indicated above. Type Of Obslructions(DesCribe) `^���'"��`� / ��� ¢ ��� <br /> Obstructions removed? ,�TYes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAI MATERIAL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated 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 /> , �t n,,r._ : .� i./�i. <br /> ❑ Annular space grouted with tremie pipe <br /> �� ❑ Casing PeAoration/Removal <br /> in.from to (1. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type oi perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> ' � <br /> / <br /> Grouting Matenal�"=����'����6m Q ro� ft. yards � bags <br /> from to tt. yards bags <br /> from to ft. yards bags <br /> trom to__ tt. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> 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 is <br /> true to the best of my knowledge. <br /> Doa Stodola Well Drilling Co. , Inc, 27172 <br /> , Contractor Business Name License or Registratlon 170. <br /> �t i� 1 3 199% �-- ___ ; . _- <br /> �% ` r�' �'' ..�' -/.--�- %'.�� <br /> � � � �Authonzed Represenfalive Signafure I Date <br /> _ _ ,,-�.� ..��'� ..�z�.�, � <br /> 13 4 9 3� Name ol Persorv Sealing Well or Boring <br /> LOCALCOPY H ' <br /> HE-01434-03 2/97 R <br />