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wELL oR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring i �c���� � <br /> County Name <br /> -- WELL AND BORING SEALING RECORD Me��lesota Unique WeII No. ��i H v � <br /> M�nnesota Sfatutes,Chapter 1031 or W-series No. <br /> ���A�p�� 0..m.um�xr�axrww�l - -- <br />�� Townshlp Name Township No Range No Section No. Fracuon�sm.-i Ig.) Date Sealed Date Well or Boring Consiructetl <br /> . �}t'0IlO ��.� �3 �� �1'*QQ'�� '� Qr} <br /> N+u�mencal Sireet Adtlress or Fire Number and Ciry ol Well or Boring�ocauon /,��� / � <br /> L.��d +7��Q1.R� �.�� Or��Q: 55391 DepthBefore5ealing�S��n. OriginatDepih__J.�Q�_ h <br /> Show exact location of v.•ell or boring Sketch map of well or bonng O IFER(S) . � STATIC WATER LEVEL <br /> in section grid with"X". locahon, showing property Single Ayuiter � Mult�aquder <br /> lines,roads,and buildings. ��- <br /> N , ,,,W,,,---///E���LUBORING Measuretl �❑ Estimated <br /> ,//,� �p Water Suppiy Well ❑MoNt.Well / <br /> -- - - -- - -- -- - J �� �/�y <br /> t� ❑ Ern.Bore Hole ❑Other L��R. �below ❑ above land surface <br /> W —'r-- -i-- -;-- --i— E .. � CASING TVPE(S) <br /> � � � � � <br /> � � � � � <br /> -�-- -�-- --�-- --�-- � - Steel � Plastic �Tile � Other <br /> }1 mile <br /> � —�- -�-- -�-- --1— � CASING(S) <br /> Diameter Depth � Set in oversize hole9 Annular space initially grouted? <br /> S ..JJ�� ,r f�`1� �l <br /> �1 mae—a. ��A.,,� � in.hom �✓ to /� k. ❑ Yes �No ❑ Ves ❑No ❑ Unknown <br /> I <br /> PROPERTV OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> P�operty owner's mailing address if rem than well lor.a ion address�n iwte above in.f�om to fl. ❑ Yes ❑ No ❑ �e5 ❑No ❑ Unknown <br /> SCREEWOPEN NOLE , <br /> Screen from�to�� ft. Open Hole from to k. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �No Obsiruction <br /> Well owner's meiling address il diflerent than property owner's adtlress indicated above. Type ot ObSlruction5(Describe) <br /> Obstruclions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR NARDNESS OF FROM TO � Removed Not Present ❑ Other <br /> FORMATION <br /> N not known,indicate estimeted formatbn log from nearby well or bodng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> _ . � ��� No Annular Space 6cists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Pertoraled ❑ Removed <br /> in.from �p n. ❑ PeRorated ❑ Removed <br /> Type of perforator <br /> ❑ Omer <br /> GROUTING MATERIAL�S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material I�EA��1 +�.�// irom � to�� h yards � bags <br /> from to ft. yards bags <br /> - from to ft. yards bags <br /> ' trom to—_ R. yards begs <br /> REMARKS,SOURCE OF DATA,DIFflCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well 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 conlained in Mis report is <br /> true to the best of my knowledge. <br /> Don St€�dola �t,�l� I3filli�g Cr�., Inc. Z7i72 <br /> Contrador Business Name License a Repishation I'ro. <br /> � /, ` <br /> r ��"..�- �..•,/ :..J- �`'`...� <br /> utho ed presentative Signa Dete <br /> `,�: v.,._, �;..�.�. .,J�.,,,�,:iti,.�,a1•.�,�. <br /> t.����� �J,����'y H 169316 NemeolPersonSeeli `WelloiBonng <br /> \.,� <br />