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Minnesota Well and Boring <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 51 ,957 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Minnesota Statutes,Chapter 103/ or W-series No. <br /> (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction ism. �Ig.) Date Sealed "� Approximate Date Well <br /> J — '=;� {� _ 11 or Boring Constructed <br /> 73 31 <br /> Drem in I 18 <br /> 4 �} <br /> Numerical Street Address or Fire Number and City of Welt or Boring Location <br /> 7 i <br /> Depth Before Sealing `� ft. Original Depth320 Mirnham Rd Orom 55159 <br /> Show exact location of well or boring Sketch map of well I r boring Static Water Level Accurate <br /> In section grid with"X. local torr.-e Pen ng prope y lines. <br /> N roads,and b ildings. Approximate <br /> p i Yf� Single Aquifer ❑Multiaquifer �v ft -- below above land surface <br /> _l_ _�_ _�_ _i_ CASING TYPE <br /> W E <br /> } <br /> -r -�- -r- -r <br /> feel ❑Plastic ❑Tile ❑Other <br /> s mile <br /> S Screen from to 1 ft. Open Hole from to ft. <br /> ,., <br /> r'"11e 1 OBSTRUCTION/DEBRIS/FILL <br /> Obstruction ❑Debris ❑Fill <br /> PROPERTY OWNER'S NAME <br /> John/Sherry Menge 475-2319 .-�-- <br /> Type ofdebris/obstruction <br /> Mailing Address if different than property address indicated above. <br /> Obstruction/Debris/Fill removed? El Yes ❑No <br /> PUMP <br /> ❑Removed )�-t Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring. rr <br /> drift 17 r� in.from O to ft ❑Yes ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes El No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> infrom to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> `y <br /> Grouting material 1 V�G..t%\.� C Vror' io to t 1 ft. yards bags <br /> from to h. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to fi yards bags <br /> RECEMED from to ft yards bags <br /> MAY8 1 UNSEALED WELLS AND BORINGS <br /> � e Other unsealed well or boring on property? El Yes �Xo <br /> C,1 /Or 1 ORONO LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Don Stodola Jell Drilling Cn.- T 27172 <br /> Contractor Business Name _ License or Registration No. <br /> 4-11-94 <br /> �ilrlih6fz'ej Representative Signature— Date <br /> LOCAL COPY H 51557 tim e <br /> Name of Person Sealing Well or Boring <br /> HE-01434-01 <br />