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w <br />�. <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12�6 Q� <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique No. <br /> x�IIlle �n Minnesota Statutes,Chapter f031 or W-series No. <br /> � (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fradion(sm.�Ig.) Date Sealed Date Well or Boring Construded <br /> flrono I18 23 26 , � � �, - � }� � <br /> Numerical Street Address or Fire Number and City of Well or Boring Location � � <br />.^.; F -�fl 5pring Iii�l Rd, �rOn� Depth Before Sealing Z'�` � ft. Original Depth ���� � ft. <br /> d_ <br />' Show exact location of well or boring Sketch map of well or Goring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". � , wing property Single Aquifer ❑ Multiaquifer <br /> µlines,roads,,aP uildings. <br /> N �tF a�^�: l WELUBORING Measured ❑ Estimated <br /> �� �:� l.�.. 3 Water Supply Well ❑Monit Well � <br /> --�- -T- --i-- --�-- � ! _...,_ .__. <br /> t � �- ❑ Env.Bore Hole ❑Other {�� tt. �below ❑ above land sucface <br /> i <br /> W -�-- -i-- -;-- --;-- E � � .._.._.._______..�..._.� CASING TYPE(S) <br /> � i i i � { <br /> --�- '�" "�-' -'�" � Steel ❑ Plastic ❑Tile ❑Other <br /> '/.mile ¢ <br /> —`- -.�-- -�-- --�-- � j CASING <br /> � Diamet�/ Depth � Set in oversize hole? Annualar space initially grouted? <br /> S """��,''' (t/ h <br /> �i mi�e--�e ���: "�'��.'. '� _, � in.from r-/ to - ��� ft. ❑Yes �No ❑Yes ❑No ❑ Unknown <br /> � V� <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Property owner's mailing address if different than II location address indicated above. in.from to ft. ❑ Yes �No ❑ Yes ❑No ❑ UnKnown <br /> 3335 P�nnsylvania A�$ � SCREEWOPENHOLE ` ` <br /> Cr3T.4t$1� 111v 5.7�27 Screenfrom to ft. OpenHolefiom �^�� to ?S` R. <br /> 09STRUCTIO WDEBRIS/FILL <br /> WELL OWNER'S NAME <br /> Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing atldress if different than property owner's address indicated above. Type of Obstruction/Debns/Fill �/�^'�'�f-��'� /����°" � /"'P=J�I'� <br /> Obstruction/Debris/Fill removed? �Yes ❑ No <br /> PUMP <br /> Type <br /> ;t..�:> �:%,.ry�p� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO 1�� Removed ❑ Not Present ❑ Other <br /> FORMATION <br />� It not known,indicate estimated tormation log from nearby well or borinq. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HO�E: <br /> No Annular Space Exits <br /> +� ❑ Annular space grouted with tremie pipe <br /> p 1 a t vi i 1 e �� G S ❑ Casing Pertoration/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to R. ❑ PeAorated ❑ Removed <br /> Type of perloraror �� <br /> � <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> � ��� / � '7 f <br /> Grouting Material J�1'f t� 'r C�-'��E/�`irom � to�._,2 ft. yards �— bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to tt. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes �No <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 report is <br /> true to the best of my knowledge. <br /> Don STodola �de11 Drilling Co. , Inc. 27172 <br /> Contracfor Business Name License or Registrallon No. <br /> _ .�'.• <br /> i {�2�'47 <br /> ori RepreS`entative Signature ' Date <br /> Jim �intonson <br /> LOCAL COPY H <br /> 12 4 6 0 7 Name of Person Sealing Well or Boring <br /> HE-01434-02 10/95F <br />