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. ��►�- <br /> �b'JELL O�BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' ��"���H <br /> ' WELL AND BORING SEALING RECORD Menneso a�Unique Well No. ;, <br /> Counry Name <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blankilnolknown) <br /> Township Na Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> '' '' !2 G T` G� <br /> , <br /> GPS Latitude degrees___ minutes_.__ seconds Depth Before Sealing / �` ft. Original Depih ft. <br /> LOCATION: Longitude degrees minutes _ seconds <br /> IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring�Ltocation �ingle Aqui(er �]Multiaquifer �^/y�F, w tj V <br /> 1940 Sisth Ave N, � SS�JS7 WELUBORING �Measured [J Estimated Date Measured�.�� �r !��7 l <br /> �Water-Supply Well ❑Monit.Well r� � <br /> Show exact location of well or boring Sketch map of well or boring '[ <br /> in sec[ion grid with"X" location,showing properry ❑Env.Bore Hole ❑Other �✓U ft. ,�below ❑above land surface <br /> ". N � es,ro�s,and buildings. CASING TYPE(S) <br /> '� --'---—'-- --`----'- � <br /> '�� Steel �,Plastic ❑Tile ❑Other <br /> - __ ---- --'_ _- _ + � WELLHEAD COMPLETION - <br /> W ET <br /> �. --•- -�--- ---� -� <br /> Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> ' � � � � M'�e itless A p r/Und ❑Buried ❑Well Pit <br /> , � � '� �P" da te � <br /> , --:--- --r-- ---�-----:- 1 <br /> ❑Well Pit ❑Buried <br /> S ❑Other__ <br /> �-1 Mile� . � ❑Other_ <br /> L � J�.r' <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> ,� Diam tek�, � Depth � Set in oversize hole? Annular space initially grouted? <br /> Proper owner mai ing dress i i er t an well location address indicated above �in.from_� to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> 1�1 �C$t r�� l�d in.from to ft. ❑Yes ❑No � Yes <br /> � ] ❑No ❑Unknown <br /> 1,I� �� � ��3� <br /> in.from to R. []Yes ❑No ❑Yes �]No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> t— • I <br /> Well owner's mailing address if different than properry owner's address indicated above SCreen from ��FJ to�ft. Open Hole from _,to_ ft. .t <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ��Check Valve(s) [�Debris ❑Fill �No Obstruction <br /> � <br /> Type of Obstructions(Describe) __.______ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> d �„ {/: TYPe <br /> �'� 'r���`i' � /'"�❑Removed (`�ot PreseM L]Other ____ <br /> A\ <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 Perforation/Removal <br /> in.from to ___ft. ❑Perforated �]Removed <br /> in.from to R ❑Perforated ❑Removed <br /> Type of Perforator <br /> [j Other <br /> GROUTING MATEFIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> GroutingMateria���rE�/�'�`�Tom Qr 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 Othei unsealed and unused well or boring on properry? �j 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 report <br /> is true to the best of my knowledge. <br /> Don Stodola Well Dcf,111ng Co., Inc. 1693 <br /> Licensee Business Name � License or Registration No. <br /> _,= ,� � /%.;J /� �� <br /> er ed Representative SignaturE " � Certilied Rep.No. Date <br /> 4 <br /> 265328 �`'. �� ��'°-'''�'-' <br /> LUGALCOPY H <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-10 IC#140-0423 � sio7a �`• <br />