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, <br /> � <br /> WELL OR BORING LOCATtON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I <br /> County Name <br /> WELL AND BORING SEALING RECORD Minne ota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Henc�e in (leeve Olenk rf rql known) <br /> Township Name Township No. Range No. Section No. Fraction(sm-�Ig) Date Sealed Date Well or Boring Constructed <br /> OCona 117 3 1 4 4 ,. �,. ,� ��>� C}� <br /> GPS Lalitude degrees minutes seconds � <br /> LOCATION: Depih Before Sealing ��� ft. Original Depth ft. <br /> Longitude degrees minutes seconds ppU1FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location �Single Aquifer ❑Multiaquifer <br /> WELLBORING J�Measured ❑Estlmated <br /> ❑Water Suppty Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid wdh"X" location,showing property ❑Env.Bore Hole ❑Other �,� ft. �(�elow ❑above land surface <br /> lines,roads, d buildings. <br /> N CASING TYPE(S) <br /> _ _;��..,5._ �.�.�-•--,'--- / � <br /> ! �teel ❑Plastic ❑Tile ❑Other <br /> T + `i <br /> W --�- - - - -- -- — E �!� � WELLHEAD COMPI.ETION <br /> �(� ���� � `� Outside: ❑Well House Inside: �Basement OHset <br /> _Y_ _i__ _l__ _i__ E.._ <br /> �^� � � , � ❑Pitless Adapter/Unit ❑Well Pit <br /> -- - -f— -�-- -�-- I �AJtl� <br /> , S , 11� 3�1"7a � ❑We��P� ❑8��� <br /> �_�'"a—a�' �/�C' ❑Buried <br /> � <br /> PROPERTY OWNER'S NAME/COMPAnNY NA_ME` p CASING(S) <br /> �P .S(,`�t t 7 S�"'Y7�1 C�� Diameter � Depth � Set in oversize hole? Annular space initially grauted? <br /> Proparty owner's mailing address if ditterent than well location address indicated above /f. <br /> �_ In.ffOm� t0�ft. ❑Yes [�o ❑Yes ❑No ❑Unknown <br /> 2S0?3 .R�3rtC88 Pr3i[!t LBt� <br /> -�" ��p,� CC M1 in.f�om to ft. ❑Yes ❑Na ❑Yes ❑No ❑Unknown <br /> JlJ7i <br /> � �� � in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> r + <br /> Well owner's mailing address if ditterent than property owner's address indicated above Screen from�t0�ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill l,�No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑ No Describe <br /> FORMATION <br /> If not known,indicate estimated formafion log from nearby well or boring PUMP <br /> Type <br /> ❑ Removed C�rNot Present ❑Other <br /> T <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PerforatioNRemoval <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 bag of bentonite=50 Ibs.) <br /> `�� ��r� i <br /> Grouting Material � C-��+�/vTfrom�to�ft. yards � bags <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 well or boring on property? ❑ Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The infortnation contained in this report is <br /> true to the best of my knowledge. <br /> Pon Stodol.a Well Dri2ling Co, Inc. 2T172 <br /> Contractor Business Name _....... License or Registration No. <br /> /. <br /> 11�1 7�� <br /> pre entative Sign,�fUie� Date <br /> Tirn SLertt�C <br /> LOCAL COPY H 2 d 31 g 0 Name o/Person Sealing Well or Boring <br />