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wELL OR BORING LOCA7iON MINNESOTA OEPARTMENT OF HFALTH M�nnesota Well and Bonng I H ������ <br /> WELL AND BORING SEALING RECORD Menne oNa Unique No. <br /> Counry Name � � ; <br /> Minnesota Statutes.Chapter 7031 or W-series No. <br /> Hc n t1 r�p i n ILeave biank A not Nnown� <br /> Township Name Township No. Range No. Section No. FracOon(sm.-►Ig� Date Sealed Date Well or Boring Consiructea <br /> ' �rono I17 23 7 , ,. 6/29j99 <br /> Numencal CStreet Address o�Fire Number and Gry of Well or Bonng location <br /> �,�(��7 R�$t. �O.L Il t. Roa d OL Qrl� Depth Betore Seahng 1 5 N. Onglnal Depth �`� n <br /> Show exact location of N�ell or boring Sketch map of well or bor�ng AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with`X`. � /{� location, s�owmg pioperty �Single Aywfer ❑ Multiaquifer <br /> -r � lines,�oads,and b ildi s. <br /> N WELUBORING �Measured ❑ Eshmated <br /> �Water Supply Well ❑Monit.Well <br /> ❑ Env.Bore Hole ❑Other _ dr 1� R. ❑below ❑ above land surface <br /> W "�' -�-- -�"- --�-' E CASING TYPE�S) <br /> � � � <br /> � � � � <br /> —�- -�-- -i— --�-- � �Steel ❑ Plastic �Tile � Other <br /> u mde ... � �� , . <br /> � CASING <br /> -�-- -�{-- --�— � <br /> � � Dlameter Depth Set in oversrze hole� Annualar space initially grouted? <br /> S _-- l <br /> ��m;�� ti � �_ m.trom� to 1 a fl. ❑ Yes �No ❑ Yes ❑No ❑ Unknown <br /> i <br /> PROPERTY OWNER'S NAME in.from to R. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> �v�iid 01sc�n <br /> Property owner's maihng address if diHereN than well loca6on adtlress Indicated above in.from to R. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> Sc�een irom 1� to x� ft. Open Hole from to R. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Dro Pi e <br /> � p p ❑ Check Valve(s) ❑Debris ❑Fill �No Obstruction <br /> Well owner's meHing address it diHerent it�en properry owner's adtlress indicated above. Type Ot ObstruCtions(Describ6) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> OEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed Ll Not Present ❑ Other <br /> FORMATION METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> It rat known,inditete estimated fortnatbn log irom nearDy well or bonng. <br /> � 15 �No Annular Space Exists <br /> ����� ❑ Annular space grouted with tremie pipe <br /> � ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> in.from to fl. ❑ PeAorated ❑ Removed <br /> Type ot peAorator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) <br /> GroutingMatenal ��rtl�l�d from �'� to � R. yards � bags <br /> from to R. yards bags <br /> irom to ft. yards begs <br /> from to_— ft. yards begs <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WEILS AND BORINGS <br /> Other unsealed and unused well or boring on property7 ❑Yes �J No How many? <br /> LICENSEO OR REGISTERED CONTRACTOR CERTFICATION <br /> This well or boring was sealed in accordence with Minnesota Rules,Chapter 4725. The infortnation contained in this report is <br /> true to the best of my knowledge. <br /> �E� Wzll 8ri�liuy �7�i� <br /> Contredor Business Name- ;'s^�� Licerrse a Rejis rio. � <br /> •/`` " S/ G'.�,.'�^i�'L: ��� <br /> e:vw ..G.i � w <br /> Authorized Representative Signature Dete <br /> .. _, _ Ja�er� L�a � <br /> �-� ! `--:�� :�c �t�-: : <br />' Name ol Person Sealing Well a Bodng <br /> LOCALCOPY <br /> HE-01434-04 8�98 R <br />