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� <br /> WELLOR 80RING LOCAnON MINNESOTA DEPARTMENT OF HFALTH M�nnesota Well and Bor�ng ; 14 40 7 8 � <br /> WELL AND BORING SEALING RECORD Sealing No H <br /> �'�1��'"e Minnesota Urnque No. — — " , <br /> }}e����yl jZ Mrnnesota Statutes,Chapter 1031 or W-series No. � <br /> (Leave b�ank A no�known) —J <br /> Tovmslep Narne � Townsliip No. Range No. Section No- fracnon�sm.-s Ig.) Date Sealed Date Well or Boring Constructetl <br /> Oronc� 1 i 7 2 s 17 � " % ���' <br /> N�rnerlcal Streel Address a Fire Number and Ciry ot Weli or Bodng�ocafion � r . <br /> i <br /> L L L J �tli�(��7WC+OC� Rf�. �c'� Z�tte� Mj-t. �P!;'� r Seabng -.%�-� tt Origlnal Depth ��� n � <br /> Stww exact br.aDon d vreb or bonng Skelch map of well o bonng AOUIFER(S) STATIC WATER LEVEL <br /> n section gd wM'X'. locatlon, showing erty S�ngle Ayuder � Multiaquifer <br /> Ifnes,roads,and bwl � <br /> N '� WELUBORING �Measured ❑ ESGmated <br /> � l� �� Water Suppry Well ❑Monit.Well � <br /> - - - - - - -i-- j <br /> T T � yv � � ❑ Env.Bore Hole ❑Other _ �� f R. �pelow ❑ above Wnd surtace <br /> � '�_. ` <br /> W -T- -T- -T- -�-- E . CASING TYPE�S) <br /> -T- --�- -i-- -i-- � ---.—�.. � ,', �Steel ❑ Plastic ❑Tile ❑Othe� <br /> \�. <br /> u mYe <br /> -1- -+- -�-- -�-- � I-__ � .�.� CASING <br /> � Diameter Depth � Set in oversize hole? Annualar space initially grouted? <br /> � g � ` � !� —, <br /> �„�� ( � -t �_ m.from� to�� ft. ❑ Yes �No ❑ �es ❑No ❑Unknown <br /> PFiOPERTY OVIMER'S NAME in.irom to fl. ❑ Yes ❑No ❑ Yes �No ❑ Unknown <br /> Todd Pie �er <br /> Ropery awners mai�g address if dAlerent than well locatwn a0d.ess indicated above. in.from to ft. ❑ Ves ❑No ❑ Yes Q No ❑ Unknown <br /> L} / � —C��7[t SCREEWOPEN HOLE <br /> I <br /> Screen irom ��� ro ��� tt. Open Hole from to f1. <br /> OBSTRUCTIONS <br /> ���aS� �Rods/Dro Pi e ❑Check Valve s ❑ Debris <br /> p p ( ) ❑Fill ❑ No Obstructbn <br /> WM oiwrrs m�ig ad�sss if diRerent Man property owners adAress indicated above. Type o(Obstructions(Describe)-^�f�'���j� �—��� g �JU�Y�/� �� <br /> Obstructionsremoved? �Yes ❑No Describe <br /> PUMP £ <br /> Type <br /> ,�L+ ( :,i(�p`\f". <br /> I;EOLOC�CAL YATEIYAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FOflMAT10N <br /> N no[Ivnw�,indeals sYmebd forms6on log from nearbY well or bonng. METHOO USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OH CASING AND BORE HOLE: <br /> f� � 'I,� ,y+9 No Annular Space Exits <br /> ` 3- ❑ Annular space grouted with tremie pipe <br /> %i ❑ Casing PeAoratioNRemoval <br /> i . <br /> in.from to ..R:`Jf ❑ PeAorated ❑ Remwed <br /> in.from to ft. ❑ PeAo�a�d ❑ Rertbved <br /> Type of perforator <br /> ❑ ott�er <br /> GROUTING MATERIAL(S) <br /> , <br /> Grouting Material ���'`� r'''�`��`�^tjlrom �-J ro��� �) tt. yards � bags <br /> from to It. yards bays <br /> from to h. yerds begs <br /> from to_— k. yaNs begs <br /> RBIARKS,SOURCE OF DATA,DIFFICULTIES IN SEAUNG OTHER W ELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Ves o How man�/l <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordence with Minnesota Rules,Chapter 4725. The irAwrt�ion caMsined in Cas repoR ia <br /> _. true to the best of my knowledge. <br /> ..,.. .. � � . <br /> �GiV ;�T(3C}C3LA WELL DRZLL7t3[i c�y -���; �� � �F <br /> � <br /> �"; Contreaor Business Name , -'� L.icense a lvo. <br /> ���:J� � � . ,� � '� <br /> ___.. . <br /> �: . ,� , � .- <br /> , ., / - / F ' <br /> �_ <br /> • ' m resenrarive slynarure � ows <br /> - ..-���"��'`'',Jl„►�1�Y`'.,.,,• <br /> 14 4`�7 8 Name ol Person Sbeling Well or Bonng ._ <br /> LOCALCOPY H 4 <br /> FiE-01434-03 2/97 R <br />