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�z.--.......�_._�m.-._...,. .;�"..,�'"�. . <br /> ... ..:,. � . .,.. . . .. . . . . <br /> -.:. . . . . ... .. . . . ... . .. . .... .. , .... . ,.. . .. �.� ..._ . . .:- . <br /> , ; <br /> MINNESOTA DEPAFTMENT OF HFALTH M�nnesola Well and Bonng � � <br /> WELL OR BORING LOCATION yyELL AND BORING SEALING RECORD Sea�ing No. H �5�Q-._j � <br /> County Name Minnesota Unique No. � � <br /> Mmnesota Stalutes.Chapter 1031 or W-series No. <br /> Hc�nnep i n 0.eave biank d no�knownl <br /> Township Name Township No. Range No. Section No. Fracaon�sm.-s Ig.) Date Sealed Date Well or Bonng Constructed <br /> 4rono 117 23 2I 2�--0�40� /(a ,f Ur� �j-`r'j <br /> Numerical Street Address or Fire Number and City of Well or Bormg Location t <br /> 2 !60 Shady�roo8 R�t�d� QXOnO Depth Before Sealing � n. Original Depth � h <br /> Show exact location of��ell or bormg g�3�1 Sketch map of well or bonng UIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, s�owing pioperty Single Aywfer ❑ Multiaq ifer <br /> Gnes,roads,and buildings. <br /> N � "" WELUBORING �Measured ❑ Estimated <br /> ��- i r Water Supply Well ❑Monit.Well� t <br /> {? ❑ Env.Bore Hole ❑Other _ C�� fl. �below ❑ above land suAace <br /> � � `� t <br /> W --i-- - -- -i— --i-- E � � CASING TYPE�S) <br /> � <br /> � <br /> � � t� � � � �T , <br /> -�- —�- -i— --�-- � ��� l� Steel � Plastic �Tile �Other <br /> � � � � F mde�... •`)� <br /> __�_ _�__ � - CASING <br /> -1-- --�-- �� <br /> '� Diameter Depth � f Set in overslze hole7 Annualar space initlally grouted? <br /> S �� � <br /> ��,�,�� , -��, in.trom � to � ft. ❑ Yes No ❑ Yes ❑No ❑ Unknown <br /> { <br /> PROPERTV OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ �es ❑ No ❑ Unknown <br /> ,��- Q 47I-�e�a <br /> � Properry owner'S mailing a0tlress B dilferem than well locauon address indicated above. in.from to R. ❑ �es ❑No ❑ �es ❑No ❑ Unknown <br /> SCREEWOPEN HOLE ' � / ! <br /> Screen from �� to � • fl. Open Hole from ro R. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ II ❑ No Obstructi��!. <br /> Well owne/s meilirp address it diflerent then property owner's address Indicated above. Type of ObslruCtions(DesCribB) ���`^-� �� � �`� -- <br /> Obstructions removed? �es ❑ No Describe <br /> PUMP ..._ <br /> Ty� J�T �'u tYl f <br /> 6EOLOfi1CAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Othe� <br /> FORMATION <br /> If not krawn,indicate estimeted tormation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> _� P �No Annular Space Exists <br /> f � f� '�J �t� ❑Annular space grouted with tremie pipe <br /> � ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> in.from to n. ❑ PeAorated ❑ Removed <br /> Type of perforalor <br /> ❑ Other <br /> GROUTING MATERIAL�S) <br /> ,�"y�� / <br /> c Grouting Matenal r`��/`�'/ ��Trom � to " " fl. yerds � bags <br /> from to fl. yards bags <br /> from to ft. yards begs <br /> from to_— ft. yards bags <br /> REMARKS,SOURCE OP DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED Op 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 ot my knowledge. <br /> Don Sto�ola W�il Drilling Ca. , Inc. 27272__ _ _ <br /> Contractor Business Name License or Repistration fJo. <br /> f _ ." > / <br /> /f s� J'¢/ <br /> / / ' � ��ni�'C^/����EM`�^�'�'.� /f� � � � �/ <br /> .�.._`: �'. ,%f'. <br /> !/�/ 1+'/� -� f �Ts'.i <br /> �presentative Signeture Date <br /> �` ., _../1��, ../l_.�_� �"-.._..,v"�...r• <br /> H � Name ol Pe Seeling Well or Bonng <br /> LOCALCOPY <br /> HE-01434-04 8/98 R <br />