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.. ,,, <br /> ;�;,� �. <br /> MINNESOTA DEPARTMENT OF HEALTH Mmnesota Well and Bor�ng � /F11 —� <br /> WELL OH BORING LOCATION Sealing No. I H �„4 6 V y�� <br /> Counry Name WELL AND BORING SEALING RECORD Minneso!a Unique No. — � <br /> IIenne �L1 Minnesota Stafutes,Chapter 1031 or W-series No � <br /> (Leave blank il not known) <br /> Township Name Township No. Range No. Section No. FracUon�sm.�Ig.) Date Sealed Date Well or Bonng Constructea <br />�' t}rono II? 23 05 1�-0822� C I�'� "i`��' <br /> Numencal Sireet Adtlress or Fire Number and City ot Well or Boring Location �� � A � <br /> V� CJ J��b«� �a Rd� Or0�0 � DepthBeforeSealing -��� ft. OnginalDepih �� h. <br /> Show exact locatlon of�•ell or bonng 5 l�590 Sketch map.plyvell nng A�UIFER(S) STATIC WATER LEVEL <br /> in sectbn gnd with'X'. � loca6on, s7l�iing operty gingle Ayurfer � Mul6aqwfer e <br /> lines,road and uil ing5�" <br /> ry �'1 � � WELUBORING �Measured ❑ EsUmated <br /> � � � � .� ' �__ � Water Supply Well ❑MoNt.Well � <br /> � � .: .___�..__....�.. <br /> ` � � �( <br /> `,g'� �`� � ❑ Ern.Bore Hole ❑Other _ (L?�' h. �}pelow ❑epwe land wAace <br /> � 1 � � � � <br /> W --'"- "�-- '�'- --�-- E CASING TYPE(S) <br /> -�-- —�- -i— --I-- � � -' " Steel � Plastic �Tile �Other <br /> --`- -�— -j-- --j-- �� CASING <br /> Diameter Depih r Set m overs�ze hole7 Mnualar space fnitially grouted9 <br /> l /,/�,, ��,,��SS <br /> �r,-�,m�e� � m.from�_ to �`� R. ❑ Yes �No ❑Yes Q No ❑Unknown <br /> I <br /> PR PERTV OWNER'S NA E m.from b ft. ❑ Yes ❑No ❑�'es ❑�'1� ❑U�k�'� <br /> �l.em Rrol� �i73-2£i33 <br /> Property ownei s mailirg adAress B AiHerent t�an well locahon address indlwted above. m.from to R. ❑Yes ❑No ❑Y� ❑� ❑Unknown <br /> Z O1 +G SCREEWOPEN MOLE <br /> Screen from �'� ' to �� , ft. Open Hole irom lo fl. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Dro Pi <br /> ❑ p pe ❑ Check Valve(s) ❑Debris ❑ Fill No Obstruction <br /> WeN owne�s msiNng atldress if tliMerent t�an property owner's adtlress indicated above. Type ot Obslructions(DesCribe) <br /> Obstructions removed? ❑Yes ❑No Describe <br /> PUMP <br /> Type <br /> (iEOLOfi1CAL MATERIAL COLOR HARDNESS OF FHOM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> If not krawn,indicate estimeted lormation log from near�y well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE MOLE: <br /> dr i f t Q �^ No Annular Space Exits <br /> t� ❑ Annular space grouted with tremie pipe <br /> ❑ Casing PeAoratioNRemoval <br /> in.irom to tl. ❑ PeAoraled ❑ Hertaved <br /> in.from to ft. ❑ Perbrated ❑ Flenwred <br /> Type of perforetor <br /> ❑ omer <br /> GROUTING MATERIAL(S) <br /> . <br /> ,/���`,t�'"c?'.����!� /, <br /> Grouting Matenal rom � ro ` `�" R yards � bags <br /> from to ft. ysrds baps <br /> trom to ft yards baqs <br /> from to__ tl. Yards bps <br /> REYARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes ❑No Fbw man�/? <br /> LICENSED OR REGISTERED CONTRACTOR CEHTIFICATION <br /> This well or bonng was sealed in accordance with Minnesota Rules,Chapter 1725. The iNormatlon oor�'eied in Uvs repat ia <br /> true to[he best of my knowledge. <br /> IIon Stodola hte11 Driiling Co. , Inc. 27172 <br /> Contractor Business Name .-^� Licerns or Rs�6a0an�io. <br /> r' ��; <br /> _-j .'�,-�,, - , j l-Ej-98 <br /> � � ��„�e��-��,�.� o� <br /> Hia Antonson <br /> LOCAL GOPY H 14 6 0 9? Name o/Person SeeNnp WeN a Boring <br /> HE-01434-03 2/97 R <br />