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� <br /> . - - <br /> MINNESOTA OEPARTMENT OF NFALTH Minnesota Well and Boring �g 7�2 4 � <br /> WELL OR BORING LOCATION �yELL AND BORING SEALING RECORD sea���9 No. �i H_ <br /> co�r,ry Name Minnesota Unique Well No. � — � <br /> ���(j(�p��(} Mmnesota Statules,Chapter 7031 or W-series No. <br /> (Laeve deMc 11 not kmwn) <br /> Township Name Township No. Range No. Sechon No Frachon(sm.-i Ig.) Date Sealed Date Well or Bonng Consiructetl <br /> Ora�o 11� � �7 ,. � �=�i` �� e,. ��-� <br /> Numencal Sir�et Address o�Flre Number and Gty ot Well or Bonng Loca6on T ` � j f�7 � <br /> �{��� �f�`��¢ �t� �j s (����� .��(�' S 5 34► epih Bebre Seal�ng /j 2 _.N Onginal Depth _ / �`^ ft <br /> Show exact locahon of well or bonng Sketch map of well or bonng ApU1FER(S) STATIC WATER LEVEL <br /> in section grid wdh"X". location, showmg property �Single Aywfer � Mulaaquder <br /> . lines,roads,a�hd buildings. <br /> N - WELVBORING �Measured ❑ Estimated <br /> i - <br /> � � � � � "' ` r ater Supply Well ❑Monit.Well <br /> � <br /> . _�_ 'i__ '_�' __� " f1 � <br /> I �-.�' —+,..--�`"- ;� � ]�Env.Bore Hole ❑Other _ 1��`��� �`�- fl [�below ❑ above land surtace <br /> W --�- - -- - -- -- -- E � �� � CASING TYPE(S) <br /> � � , <br /> � � � � <br /> � ` e S� <br /> ---- -- -r - �-- � �. � I XSteel ❑ Plasfic �Tile �Other <br /> � ' ' '- ' y,.. <br /> � � � Yemi1B �, j ' f <br /> � -�- �- --�-- --�— � �_ E E _. � CASING(S) <br /> _ - i t Diameter � Depth ` Set in oversize hole� Annular space initially grouted� <br /> l� S � f(a� <br /> �11�i miie� � _ in.from to tt. ❑ Ves �No ❑ Yes ❑No ❑ Unknown <br /> I <br /> PROPERTV OWNER'S NAME in.irom �o ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> �Q�7R �].�1RE' ''R3 @5�1 <br /> Property owner's mailing address if diRerent than well location address indicated above. in.irom to ft. ❑ Yes ❑ No ❑ �e5 ❑ No ❑ Unknown <br /> � �f � SCREEWOPEN HOLE <br /> � / <br /> /f'i,'!' '//�� <br /> Screen�rom j �- to� ft. Open Hole from to R. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Dro Pi e <br /> ❑ p p ❑ Check Valve(s) ❑ Debris ❑ Fill No Obstruction <br /> Well ownets mailing address if diflerent than property owner's address mdicatad above. Type ot ObstruCtiOns(D85Cribe) <br /> Obstructions removed7 ❑ Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COIOR HARDNESS OF FROM Tp � Removed Not Present ❑ Other <br /> FORMATION <br /> II not krrown,indicate estimeted formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> '} No Annular Space 6cists <br /> :3 r i f t � +� ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> in.from �o n, ❑ 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 /> Grouting Matenal ��!%� ;��� '"`�flbrtf�`� �% to ��f ftr yartls �{ bags <br /> from ro R. yards bags <br /> from to ft. yards bags <br /> from to__ R. yards bags <br /> REMARKS,SOURCE OF DATA,DIFflCULT1ES 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 accordance with Minnesota Rules,Chapter 4725. The information contained in this repoA is <br /> true to the best of my knowledge. <br /> �an ��ot.�a�a I��e11 €)�iTlir��; Go, . Ir�c. 27�I?� <br /> Contractor Bus�ness ame _ . , License a Regisfra6on I'ro. <br /> � `,� �� <br /> ,' /�- f�" �`--� � �"3 C�-i�7 <br /> - ,;�. .� 'r ._� f � <br /> pn F�epresentative Signature Date <br /> ..T�.tE1 �fitOt!!�� <br /> H 1 g.7,?2 4 Name ol Person Sealing Well or Bonng <br /> LOCALCOPY <br />