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.� <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I,,,I�� I� <br /> County Name <br /> WELL AND BORING SEALING RECORD MennlegoNa Unique Well No. � <br /> ��� in Minnesota Statutes,Chapter 1031 or W-series No. <br /> (�eave blank ii not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm-►Ig) Date Sealed Date Well or Boring Constructed <br /> Ora�o 117 23 7 4 1��3 �,. � / ..,,�' � <br /> GPS Latitude degrees minutes seconds � <br /> LOCATION: Depih Before Sealing �� ft. Original Depth � ft. <br /> Longitude degrees minutes seconds IFER(S) STATIC WATER LEVEL <br /> Numerical Sheet Address or Fire Number and City of Well or Boring Location �ingle Aquifer ❑Multiaquifer _. <br /> 1(VEyL/BORING �Measured ❑Estimated /J ' <br /> a! <br /> ��+Water Supply Well ❑Monit.Well r <br /> Show exact location of well or boring Skefch map of well or b � " <br /> in section grid with"X" location,showing prope y l ❑Env.Bore Hole ❑Other �/ ft. ,�below ❑above land surface ` <br /> � <br /> H lines,roads,and buildin �' CASING TYPE(S) <br /> - - - — -- -- -- — '"t� . <br /> �� [�aSteel ❑Plastic ❑Tile ❑Other s <br /> W -- - - — - -- -- -- E �' WELLHEAD COMPLETION <br /> � � ; � � ,� Outside: ❑Well House Inside: ❑Basement Offset `- <br /> �m'� `� ❑ Pitless AdaptedUnit ❑Well Pit . <br /> -�— -i-- -i-- --�-- � � .,, ,' <br /> A . `� �Well Pit ❑Buried <br /> �im�le� �.�7-�� <br /> ❑ Buried <br /> PROPJER,�TY OWNER'S NAME/COMPANY NAME CASING(S) <br /> T1117 �.�.t 952-�i72-0246 DiarrrLeete�� � Depth O � Set in oversize hole? Annular space initially grouted? <br /> ' <br /> Property owner's mailing address if different than well location address indicated above L <br /> in.from to�ft. ❑Yes [�o ❑Yes ❑ No ❑Unknown <br /> 4578 I�enbigh Rd <br /> �' �T �CqC/_ in.from to ft. ❑Yes ❑ No ❑Yes ❑ No ❑Unknown <br /> CI11 J�C)'t <br /> r <br /> in.ffom t0 ft. ❑Yes ❑ No ❑Yes ❑ No ❑ Unknown <br /> WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � r i� <br /> 4,` { <br /> Well owner's mailing address if different than property owner's address indicated above Screen from�t0 � t ft. Open Hole from t0 ft. !� <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑ Check Valve s) ❑ Debris Fill ❑ No Obstruction � <br /> Type of Obstructions(Describe) <br /> --�/i1N/`,� r`"'"��. ¢ c.��-.,� , <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? S ❑ NO D2SCIibB <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP �� � <br /> r'` � TYP <br /> �L / uM� <br /> `' � �'J � -) (�Removed ❑ Not Present ❑Other <br /> ( <br /> � <br /> " METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASWGS,OR CASING AND BORE HOLE: <br /> �Vo Annular Space Exists ❑ Annular space grouted with iremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bagt o�f b¢ntonite=50 Ibs.) <br /> Grouting Material /"�1'*� ""���m � to � " ft. yards � ba s <br /> 9 <br /> from to ft. yards bags <br /> from to ft. yards _ bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused weil or boring on property? ❑ Yes No 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 /> Don Stoclola Well Driiling Co. Inc. 27172 <br /> Contracto�8 siness Name ' License or Registration No. <br /> �;s- - ,'� :.��_ .:�-.�'�.,� G�/ <br /> ut orized R presentative Signature Date <br /> 218193 `� k <br /> LOCAL COPY H �� * Y' ~�� ��~���`•~� <br /> Name ol Person Sealing Well or Boring � <br />