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�Li+)"�F l35y`..1� <br /> . f..� ���� .c..�. <br /> -....:. :. .. ..::......s. ..... , ...�. t . . � . �` .. ., <br /> WELL OR BOFING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Weil and Boriny ; 136�5 0 � ; <br /> County Name WELL AND BORING SEALING RECORD Sea"�g"°. i H _ _.. <br /> Minnesota Unique No. � — � <br /> ji�.a����.a�l� Minnesota Statutes,Chapter 1031 or W-series No. <br /> ILeave blank if not known) <br /> Township Name Townshlp No. Range No. Seclion No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Consiructed <br /> Oron� �17 23 2 , ; , 6/t7/��3 <br /> Numerical Street Adtlress or Fire Number and City of Well o�Bonng Location <br /> 1.30V ShuteYine L�r�.�@ DepthBetoreSealing �� ft. OriginalDepth f.� h. <br /> Show exact locatwn of K•ell or boring -\ Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". A /- 1 location, showing property �Single Ayuifer ❑ Multiaquifer <br /> !v ! lines,roads,and buildings. <br /> N WELUBORING �] Measured ❑ EsGmated <br /> � � � � „ n ^ �]Water Supply Well ❑Monit.Wetl <br /> -�- -�-- --i-- --� ci,` t <br /> � V <br /> jU �. ' ,. ❑ Ern.Bore Hole ❑Other _ ��l tt. ❑below ❑ above land surface � <br /> -�- -=-- --=-- ----- <br /> x � !� <br /> yy E i' CASING TYPE(S) - <br /> � � � � <br /> � � � <br /> � � � � <br /> —�- —�- --i-- --�-- � i. $�Steel ❑ Plastic ❑Tile ❑ Other <br /> %md9 „ n. .'� . . . � <br /> • �, ,, . . � ` �; � <br /> ' ' ' ' ��' .' .. � CASING <br /> —�- -�-- -�-- --�-- <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> S '��J"� .;{ i,: 'r, �. ;-._i ! - i l � �3 <br /> �r mi�e—�e in.6om to ft. ❑ Yes �No ❑ Yes ❑ No ❑ Unknown <br /> I <br /> PROPERTV O ER'S NAM in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> r;on �oa�ar� <br /> Property owner's mailing address if diHerent ihan well location address indicated above. in.from to ft. ❑ Ves ❑No ❑ Yes ❑ No ❑ Unknown <br /> LL�O S• PI�tLil�uti� Ri,�CZA SCREEWOPENHOLE <br /> �1 rltli3t'iOL1Kd� � �J�J 3 a� Screen from l'} to l? ft. Open Hole from ro ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME ,$] Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill�]No Obstruction <br /> Well owner's mailing address if different than propeAy owner's atldress indicated above. Type of Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> �EOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed Q Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated tormation log from neaiby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> a►r i f t � �� � No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforetion/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Matenal��r�1��� trom �7 to v ft. yards 1 bags <br /> . from to ft. yards bags <br /> from to ft. yards bags <br /> from to_ k. yards bags <br /> REMAHKS,SOURCE OF DATA,DIFFICULTIES 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 contained in this repoR is <br /> true to the best of my knowledge. <br /> itEs i��11 t�rilli�� 2727b <br /> Contracror Business Name / License or Regishation lvo. <br /> � / <br /> ,.. _. <br /> � � - : <br /> r <br /> ! r- ' � f�,�:. " . 1�- / J /�' <br /> _ � '.� , <br /> Authorized Representafive Signature ate - � <br /> Jam�� i,ea <br /> LOCALCOPY H <br /> 13 6 6 5 0 Name ol Person Sealing Well or Bonng <br /> HE•01434-03 2/97 R <br />