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� <br /> . - <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ���n�� � <br /> WELL OF BORING LOCATION Sealing No. ��H_ a <br /> �o���Y Name -- — WELL AND BORING SEALING RECORD M;�„esota u��q�e we��No. r -- � <br /> �e�A$p�A Minnesota Statutes.Chapter 1031 or W-series No. �— <br /> �Leaw denk rc na known� <br /> Township Name j Township No. �Range No Section No. Fracuon 1sm.-i Ig 1 Date Sealed Date Well or Boring Constructed <br /> Otono ; 217 Z 08 3�1-� <br /> � <br /> Numeprical Street Adtlress or Fire Number and Gry of Well or Bonng Locat�on ( / <br /> 1.7Q+F 881���. P�rA A�,� Or,Od� SS37 Depth Before Sea6ng��____fl Original Depth 9�1 h <br /> Show exact location of v.�ell or boring Sketch map of weil or boring A IFER(S) STATIC WATER LEVEL <br /> m section gnd with"X". �i locatwn, showmg property Single Aqurfer ❑ MWtiaquifer <br /> 1 lines,roads,and buildings <br /> N WELL/BORING Measured ❑ Eshmated <br /> � ' I I , � Env.BorePHole ❑OtheL Well t <br /> ; Water Su I Well ❑Mon �7,� <br /> I � � ❑ r _ _�L.�—ft. IRbelow ❑ above land surtace <br /> �� r- <br /> W --�- - -- - -- -- -- E CASING TYPE�S) <br /> � , , <br /> � � � i i� \, <br /> � —�- -;-- -;-- --�— � ; _� Steel ❑ Plastic �Tlle � Other <br /> LL i � <br /> /[mI�B <br /> --�- -i-- -�-- --i— � � CASING(S) <br /> Diameter Depth � Set m oversize hole? Annular space initially grouted? <br /> S �i �� <br /> � Yes �No ❑ Yes ❑No ❑ Unknown <br /> ��m,��{, _�,�_ in.irom O to R. ❑ <br /> I <br /> PROPERTV OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Property ownei s mailing address d erent than well iocation address indicated above. in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SBAe 8$ BbOY� SCREEWOPEN HOLE ' � <br /> Screen from_�_to� ft. Open Hole from to tt. <br /> 08STRUCTIONS <br /> WELL OWNEF'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No ObsVuction <br /> •�-�- <br /> Well owners mailing a0dress it diBerent than properry owner's address indicated above. Type of ObS�ructions(Describe) ��� ,o.�E� �- P�n�P <br /> Obstruclions removed? Yes ❑ No Describe <br /> PUMP /� <br /> TYPe b'��Cl��L�1 <br /> 6EOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If rat known,indicate estimated formatbn log from nearby well or boring. �METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �o Annular Space Exists <br /> �� r <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ PeAoreted ❑ Removed <br /> in.from �o ry. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ otner <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.} <br /> Grouting Matenal r6m _� to�_ h _ __ ya�ds _ � hags <br /> 5. <br /> --_ trom to R. yards bags <br /> from to ft. yerds begs <br /> from to__ fl. yards bags <br /> �., ._._r.:_., <br /> � REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS ANO BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This weli or boring was sealed in accord n„e svitF F n � �.o!=Floles,Ch�pr� -_: - ,,-nc,i�o�:;ntainin�i-�n inia�sport ie <br /> true ro the best of my knowledge. <br /> " �a Stodols �iel.l Drilling Co., Ioa. 27ITZ <br /> Contractor 6us;ness Namc License or Regisfrefion hip. <br /> � ,,,�- ,5- Q ! <br /> � - � e resentative Signa�uYe � pete <br /> � �iIM1IYY� �../`.."Y`/ '."'1I^h.,,I�!„�}�""y'�"'+...r <br /> 1` ___. . _.___ __— <br /> �d��!_���y H �w�^�� Name ol Person�ing Well or Boring <br /> i M <br />