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� Minnesota Well and Boring WELL OR BORiNG LOCATION MINNESOTA DEPARTMENT OF HEALTH SeaGng No. H � ? �o��Y Name WELL AND BORING SEALING RECORD^^��eso�a u��q�e No �P� Mmnesofa Staiutes.Chapter 103/ o�w-se�ies No. S�1S5O2 �Leave b�ank i�no�knownl Township Name Townsh�p No Range No Section No Fraction(sm •Ig.� Date Sealed Approximate Date Well � �4� �� I/a 'I, 14 � or Bonng Consiruc�ed �� L Numencal SUeet Address or Fve Number and Gty of Well or Bonng Locahon 32h5 Ct � U 5535b Deplh Before Seahng Z�� fl Onginal Depih �1}a�� ft. Show exact localwn ol well or bonng Skelch map of well or bonng Sta6c Water Level �Accurate in secUon gnd wdh"X location.showmg propeny hnes. --rcadz.aod,buddings. ❑Approxima�e N r t I � -�- --- -� �- � ,�[ QS i- -i ' I I � -- U'Single Aquder ❑Multiaquifer �tt. x below aboe�e land surtace -�- -�- - - -�- i CASING TVPE � W ` i T (-..._. _ '_ _�_ _r_ _i_ -� ]� i i i �` ❑Steel L7 Plashc ❑Tde ❑Olher �mi4 _i_ O� ; _i_ � �----�"�"'�� Screen from �� lo �� fl. Open Hole irom to ft S ...--. ��'"'�� O,�B[STRUCTION/DEBRIS/FILL � � LTObslruc�ion ❑Debns ❑RII I PROPERTY OWNER'S NAME Dvn �IeI aber ir�er pipe w/�u1�. �p Type ol debns/obsiruc�ion . Mading Address�I ddferent than property address�ndicated above. y, Obs�ruction/Debris/Fill removed� LJ Yes ❑No PUMP LSRemoved ❑Not Present ❑ Other CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO . FORMATION Diameter Depih Set m oversize hole? Annular space mrtially grouted? II not known,indica�e eslimated formation log from nearby well or bonng. w in.irom O to �� ft. ❑Yes �No ❑Ves ❑No ❑Unknown �7► �J i 30 �� 1�9 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.(rom to tt. ❑Yes ❑No ❑Yes ❑No ❑Unknown METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists ❑Annular space grouted with iremie pipe �� ❑Casing PerforationlFemoval in.(rom �o fl. ❑Per�oraled ❑Rer�noved in.irom �o ft. ❑Per�orated ❑Removed Type of perforalor ❑Other GROUTING MATERIAL T1P_8t CP.L�![]t I� Grouting matenal from to � � tt. yards bags from to ft. yards bags � REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING from to t�. yards bags �.,�,� from �o ft. yards � bags UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑Yes t7 No �ICENSED OR REGISTEHED CONTRACTOR CERTIFICATION � This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The mformahon contained in Ihis report is � irue to ihe best of my knowledge. � �PN � 2 199�0 I7an Stodola '�TeII $ri1li� Co., Inc. 27�72 Confractor Business me Lrcense or Reg�sbafron No -- --i fr23-95 �?. ufh �zed Representative Signafurt Date Jim Axrtanson t1��,��' •• ��7 Name ol Person Seal�ng Well or Bonng HE-01434-Oi