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y MINNESOTA DEPARTMENT OF HFALTH M�nnesota Wef and Bonng i <br /> WELL OR BORING LOCATION Sealmg No I�"� �� "���S � <br /> Counry Name WELL AND BORING SEALING RECORD M,��eso,a��,q�e No r � <br /> p Minnesota Statutes,Chapter 1031 or W-senes No. I <br /> Henne in l�eave biank�I not known� L <br /> Townshlp Name Township No. Range No. Section No. Fractwn(sm.-s Ig.) Date Sealed Date Well or Boring Constructed <br /> Qrono 127 23 - <br /> Numerical Sheel Adtlress or Fire Number and Ciry of Well or Bonng Location /']�/ t/]� � <br /> �8 5 .[7� �1 e R Depth Before Sealing ,""r R. Original Depth . f`�� h <br /> Show exact Ixation of�-ell or boring Sketch map of well or bor�ng A UIFER(S) STATIC WATER IEVEL <br /> m section giid with'X'. locauon, showing property Single Aywfer ❑ Multiaquiter <br /> lines,roads,and bwldings <br /> N W LUBOFiING Measured ❑ Estimated <br /> , �_ Water Supply Well ❑Monit Well / <br /> _ _ _T_ _ _ <br /> ❑ Env.Bore Hole ❑Other _ _ � H. �below ❑ above land surtace <br /> W —�- -i-- -i— -- -- E CASING TVPE(S) <br /> � � � <br /> � <br /> � � � � ' <br /> —�- -;-- -�-- --�-- � Steel ❑ Plastic ❑Tile � Other <br /> ti mrle <br /> ` I CASING <br /> -�-- --i-- --i-- � <br /> � � Diameter Depth � Set in oversrze hole7 Annualar space mitially grouted? <br /> � S �� � <br /> �m�� `�� �_ in trom � to �� ft. ❑ Yes No ❑ �es ❑No ❑ Unknown <br /> PROPERTV OWNER'S NAME in.from to R. ❑ Ves ❑No ❑ Yes ❑No ❑ Unknown <br /> Property ownei s mailing aWress if diflerent than well locafion address indlcated above. in.from to tt. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> 2II2 S FL�X S t SCHEEWOPEN MOLE r <br /> / <br /> w�y�i��i� t`il' 5 5 391 Screen from J�to /� ft. Open Hole from to R. <br /> �t 7 3!2 78 3 ossraucnoNs <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �lo Obsiruction <br /> Well owner's mailing a4Aress if diflereN Man properry owner's adtlress indicated above. Type Of ObstruClions(DesCribe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> 6EOLOOICAL MATERIAL COIOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION � <br /> If rat krawn,indicate esUmated formatan log from nearby well or boring. M�E,yT{HOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE: <br /> J4J No Annular Space Exists <br /> �� ❑Annular space grouted with tremie pipe <br /> � � ❑ Casing Perforation/Removal <br /> f <br /> in.from !o ft. ❑ PeAorated ❑ Removed <br /> in.from �o ry. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> rr <br /> GroutingMatenal�"" ��-'�'''�'�" from Q to! � 'R. yards � bags <br /> from to R. yards bags <br /> from to fl. yards bags <br /> f�om to__ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on propeAy7 ❑Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in eccordance with Minnesota Rules,Chapter 4725. The information confeined in this report is <br /> true to the best ot my knowledge. <br /> Don Stodola We31 Dri.11i�g Co. , Inc. 27172 <br /> Conhedor Business Na r ,t License a Registrefbn I'.o. <br /> ._,_.��./'� f� �� � <,, -� <br /> �:�r <br /> A nz epresenfative Sig Nre' Dete <br /> �� ; � y/I�.�.. <br /> .r"'./1. "J'✓-�1a��./'e...1_� 'Y �1.� <br /> Name ol Persan ling Well or Boring <br /> LOCAL COPY �"� <br /> HE-01434-04 8�98 R <br />