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. ;� <br /> WELL OR 80RING LOCATION MINNESOTA DEPARTMENT OF HF_ALTH Minnesota Well and Boring j �� i +! �Q � <br /> ` Counry Name WELL AND BORING SEALING RECORD Sealing No. �H i}1 t� <br /> Minnesota Unique Well Na r-- — � <br /> "�nn��in Mrnnesota Stalutes.Chapter)031 or W-series No. I <br /> tiwve dan�n na k�own� L_ <br /> Township Name Township No. Range No. Section No. Fraction�sm.i Ig.) Date Sealed Date Well or Bonng Constructed <br /> OCOQO �.�.c� �3 Z� . ,. • ,.,%�:..�� � } <br /> Numerical Street Adtlress or Fve Number and Gry of Well or Boring�ocauon /,�/ ' <br /> f�tl:�5 �t� �i.t1 �?� t)r,n�c�, :-11.? S�.?�U Depth Before Sealmg_f__��___Ft Original Depth / T � fl <br /> Show exact bcation of v,•ell or bormg Sketch map of well or bonng A�UIFER�S) STATIC WATER LEVEL <br /> in section gnd wdh"X'. location, showing property Single Aqwfer � Muthaqwfer <br /> � lines,rpads,and butldings. <br /> ry . y_ � . �UBORING Measured ❑ Estimated <br /> � � � � ; Water Supply Well ❑MONt.Well � <br /> ___ _ __ _ __ __ __ . .. ��,��' <br /> .._.. � ❑ Em Bore Hole ❑Other __ � -�-�- R. �below ❑ above land surface <br /> ,� — <br /> W -- - - -- -''- -' -- E � CASING TYPE�S) <br /> S O <br /> ' I I I . <br /> —�- -�— --i-- --i— � �` . ;,� � . �teel ❑ Plastic �Tile �Other <br /> .. I � � }lmile�4 � � � 1 <br /> —�- �— -� --i-- � i I CASING(S) <br /> . � � � � l ,� <br /> : i � - , Diam ter Depth f�` � Set in oversize hole� Annular space initially grouted? <br /> S J" i � � f� " I�7 J <br /> �i miie—qw ��--"""'^"--�� � - m.from� to - ft. ❑ Yes �o ❑ Yes ❑No ❑ Unknown <br /> I <br /> PROPERTY WNER'S NAME m.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Jo��n�?3iRne �aresh <br /> Property ownei s mailing address if ditFerent than well locafion address indicated above. in.from to ft. ❑ �es ❑No ❑ �es ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> f ;..-� Screen trom! �/ '': to�L fl. Open Hole from to ft. <br /> ' +} <br /> -` OBSTRUCTIONS <br /> WELL OWNER'S NAME Ial Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> T j ,y�I <br /> Well owner's mailing aAOress if diflerent than property owner's atldress Indicated above. Type ot Obstruclions(Describe) ��l,j{-�/%��� �f���'� �/ ��/��-�I' <br /> Obstructions removed? es ❑ No Describe <br /> PUMP <br /> 7ype l~'�.if�` � t.f}��l✓ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> It not known,irWicete estimated formation log from nearby well w bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> '�7�IGo Annular Space F�cists <br /> � :?f l` <br /> , ❑Annular space grouted with tremie pipe <br /> � ❑Casing Perforation/Removal <br /> in,from to fl. ❑ Pertorated ❑ Removed <br /> in.irom to ft. ❑ Pertorated ❑ Removed <br /> Type of peAoretor <br /> ❑ Omer <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 Ibs.) <br /> ?"� �t �"' ' —L':.�� <br /> Grouting Material �t�'`�}T`� - ;"14oi�'S r� to r R. yaras bags <br />'�� from to ft. yards bags <br /> from to R. yards bags <br /> from to__ tt. yards bags <br /> REMARKS,SOURCE OF DATA,OIFflCULT1ES IN SEALING OTHER WELLS AND BORINGS <br /> 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 accorda�ce with Minnesota Rules,Chapter 4725. The information contained in this repoA is <br /> true to the best of my knowledge. <br /> - ��ar+ ��ac�o1�� t�ell F3rf12in� Ca. , inc. Z7T.�2 <br /> Contracror Busingss yeme License a Registretion Yio. <br /> ;�. f: A� ..• _, <br /> . _. r j .�: 1„ <br /> - -y� <br /> y'` � d <br /> RWhonred Repre3entative Signeture �� Dete <br /> � . . . . j� . . -_J <br /> LOCALCOPY <br /> H 19 413 8 Name ol Person Seeling Well or Bonng <br />