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MINNESOTA DEPARTMENT OF HFALTH M�nnesota Well and Boring � y) WELL OR BORING LOCATION Sealing No. ��"� �,�9 i �s� County Name WELL AND BORING SEALING RECORD M�nnesota Urnque No. a., ; , z;{.,, Mmnesota Statutes,Chapter 1031 or W-series No. � � �� ILeave blank 1 nol known) Township Name Township No. Range No. Section No. Fraction(sm.-►Ig.) Date Sealed Date Well or Bonng Constructed : `1') s iir.rr��.�� li7'�' :'�4Y 7 �� ?':� i� lI—.��-00 Numerical Street Adtlress o�Fire Number and Ciry of Well or 8oring Localion /� ��'.7t�i C�)2"l1�::P ��.r'�C+='� �:'07'i� Depth Before Seahng Zv� _ft. Original Depth. n� �' Show exact locatwn of w•ell or poring Sketch map of well or bonng �IFER(S) STATIC WATER LEVEL j in section grid with"X`. locauon, showing property ingle Ayuder ❑ Multiaquiter * lines,roads.and buildings. � N WELUBORING �Measured ❑ Esfimated -_ [�Nater Suppiy Well ❑Monit Well 43 � Env.Bore Hole ❑Other ft. �]below ❑above land surface . W --�- -i-- -i-- --i— E CASING TYPE(S) � � � � � � � � , -'r- -i-- -;-- --�1-- -� [[�,Steel ❑ Plasfic ❑Tile ❑ Other__ ' k mile ' ' ' ' � CASING --`- ---- -�-- --i- Diameter Depih Set in oversize hole? qnnualar space initially grouted? S !� �(}/1 � � ��m�� `� in.from� to_L�tSL ft. ❑Yes ��No ❑Yes ❑No /-'i Unknown '—ti PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown �yi �.3- .C.. �':�7 s�. Property owner's mailing address if ElHerent than well loca[ion address indicated above. in.hom to R. ❑ Ye5 ❑No ❑ �es ❑No ❑ Unknown L G .�i�i> FJ33 SCREEWOPEN MOLE ��L 1�� : s�..,.,�: i:;' �:iv >j.3�i{ Screen hom to ft. Open Hole from to R. OBSTRUCTIONS WEII OWNER'S NAME ❑ Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction th�.i. l:..L�:::iC:.�i _�P:.u:.�� . Well ownefs meiling address if tliflerent ihan property owner's address indicatetl aDove. Type ot Obstruclions(Describe) �:'??"•= ObsVuctions removed? ❑Yes ❑ No Describe PUMP Type GEOLO(i1CAL MATERIAL COLOH MARDNESS OF FROM TO d Removed ❑ Not Present ❑ Other FORMATION H not krawn,indicate estimeted formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOI.E: � �No Annular Space Exists ❑Annular space grouted with tremie pipe � ❑Casing Perioration/Removal in.from to it. ❑ Pertorated ❑ Removed in.from to R. ❑ PeAorated ❑ Removed ' Type of perforator i ❑ Omer GROUTING MATERIAL(S) �": '� C�ard•._:.., , Grouting Matenal� `• � from � ro �� ft. yards b bags from to ft. yards bays from to ft. yards begs from to__ R. yards bags � REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS ur��kns�wd; Other unsealed and unused well or boring on property? ❑Yes ❑No How many? i LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance wiM Minnesota Fules,Chapter 4725. The infortnation conteined in Mis report is true to Ihe best of my knowledge. 17V�'t.f1..}e:J �1 ..15..._ !Z � .��Y �_., :1. ��.`� a�i � iVJ�� -;g __ S^c. �� Contredor Business Name License a Registretion I'io. � •� � _.._.._._ .___ �� /�y{ C _. fl"'�� G!U ' AuMorized Representative Signature Dete kfcti:�rc1 S�s..>f::�:: H � Neme ol Person Sealing Well or Boring WCAL COPY HE-01434-04 8�98 R