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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring I H �� e ��I� —� <br /> Counry Name WELL AND BORING SEALING RECORD Sealing No. � r} C <br /> Minnesota Unique Well No. <br /> '#�������� M�nnesota Statu�es,Chapte�]031 or W-series No. I <br /> (Leeva HaMc 11 not known) �--_"__— J <br /> Townshlp Name Township No. Range No Section No. Frachon�sm.i Ig.) Date Sealed Date Well or Boring Constructec] <br /> f?X O Il0 Z�.� Z� �� Z�S—`�C�� C" ,;�,� - ,.... <br /> Num(e�rical Sireet yA,ddress or Fire Number Ta�nd City ol/W�ell or Bonng Location ^� � <br /> 1J��> �lt.c`�C��C�oQ� iid� VrQn� 553�1 DepthBeforeSeahng �?G { R OriginalDepth � /4. ft <br /> Show exact bcation of well or boring Sketch map ol well or bonng OUIFER(S) STATIC WATER LEVEL <br /> m section grid wlth"X". ,\ location, showing propeny � Single Ayuder ❑ Multiaquder <br /> � lines,�oads,and buildings. ]/ <br /> N ':y} WELVBORING ILrMeasured ❑ Eshmated <br /> � � � � � �';�^ � �Wa1er Suppry Well ❑Monit.Well . <br /> -�- -�-- —;-- — . � <br /> -- ,t�� � � <br /> . � ❑ Env.Bore Hole ❑Other _�ft. (�pelow ❑ above land surtace <br /> W —i-- -i-- -i-- --i— E _ CASING TYPE(S) <br /> � � � .,, �_._.�._�. <br /> � � � ` .� 4 <br /> � � � �/ <br /> -�— -�- -�-- --�- � �.•� � I ySteel ❑ Plastic �Tile � Other <br /> }�mile { �r <br /> ' -�-- -�-- -�-- --�— • t CASING(S) <br /> S ' ��y.�� M Z\; Diamete�� Depth ( Set in oversize hole7 Annular spaCe initially grouted? <br /> \ va. L// <br /> �i mire� -J�i �'✓� % �.� � in.from� to��. ❑ Yes �o ❑ �es ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> - Properry owner's mailing address if diMerem than weil iocanon address�ndicated above. in.from to R. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> ?(�A �i' La�� f�.'L SCREEWOPEN HOLE <br /> �d�t f � <br /> t��yzat a, t"dkY 5 5�9 I Screen trom��_to�.� tt Open Hole from to tt. <br /> �.L Ctl:�E'LQCI'S Tessier oesraucnoNs <br /> WELL OWNER'S NAME w + (�/Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction/'� <br /> Well owner's mailing address it diflerent than property owner's address indicatetl above. T p of Obs�ruClions(DeSClibe) �/�/L-'�l��. �� �� e' U//// ) <br /> Obstructions removed? [�es ❑ No Describe <br /> PUMP <br /> TYPe�G�UJ,+S ��/l�lf <br /> 6EOL0(i1CAL MATERIAL COLOR HARDNESS OF FHOM Tp �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> N not krwwn,intlicate estimated formation log from nearby well or ponnq. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> . ,s�o Annular Space 6cists <br /> � ") ' ���� <br /> �Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> r <br /> in.from to k. ❑ Pertorated ❑ Removed <br /> in.irom to ft. ❑ PeAorated ❑ Removed <br /> Type ot pertorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> i <br /> Grouting Material 1�✓''�� � �5"' -`��146�� to�R. yards � bags <br /> irom to ft. yards bags <br /> irom to ft. yerds bags <br /> from to__ ft. yards bags <br /> qEMARKS,SOURCE OF DATA,DIFflCULT1ES 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 /> �?c���z '::�to�3o�.� rt�7ell Drilli.n > �o. Irac. 27I7� <br /> Contracror Business me - �� License or Registration I'ro. <br /> ,�� tF�'�rr�l���' ��T� ��i .:�C,` <br /> •l.� �. .g � <br /> AifironzbARepiesenfative Signature � Defe <br /> 1 <br /> � � . . ,'i;'' ' ;..,_ ._...v <br /> H �+ �� l � Name o!Person Sealir�tj,Well or Bonng <br /> LOCAL COPY a � <br />