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.. . _. . T..� . _ _. . . ..... .� ,._ ^ _ _. T -� _ _ ,- <br /> MINNESOTA DEPARTMENT OF HEALTH M�nnesota Well and Bor�ng ` 7-� Y <br />� WELL OR BORING LOCATION g I H 1�1 5 ( � <br /> WELL AND BORING SEALING RECORD Sealin No. <br /> Counry Name I-- — <br /> Minneso;a Unique No. � <br /> t:ti:lEl4r't.l:: Mmnesota Statutes,Chapter 1031 or W-series No. <br /> ILeave blank A nol known� <br /> Township Name Townshi No. Range No. Section No. Fracuon�sm.-►Ig.) Date Sealed Date Well or Boring Consinictea <br /> Oronc� i i€� 2:, 31 <br /> , <br /> ti N F��: �; ��� <br /> Numencal Street Adtlress or Fire Number and City o�Well or Bonng locaUon � ` ,` l <br /> F4%�i.�) B$��.3.�� ��3C�C.� Q�Q��i� p'�•,Gi�j �Pth Bebre Sealing �� ft. Original Depth �.l Y ft. <br />�_ Show exad loca6on of w•ell or boring t $ketch map of well or bonng A UIFER(S) STATIC WA7ER LEVEL �� <br /> in section gnd wdh'X'. k I�cahon, showmg property Single Aqurfer � Mulfiaquiter <br /> �--'""'fines,roads,and buildings. � <br /> N . ---. . WE UBORING Measured ❑ EsNmated <br /> ; 4! � Water Suppty Well ❑Monit.Well ( <br /> - - - - - -- - -- .. �� � t ❑ Env.Bo�e Hole ❑Other _ �R. �pelow ❑aprn,e land suAace <br /> � � � � <br /> � � � � : ; <br /> � � � � ! f <br /> W --�- -�-- -�-- --�-- E � � .-.._ CASINGTYPE(S) <br /> � <br /> � � <br /> � � <br /> , * � ' t <br /> --'r- -�-- -;-- —i-- � )4 � �teel � Plastic �Tile �Other <br /> ;�mde ., -._..._,._ <br /> --�- -j-- -�-- -�-- � CASING <br /> Dlamet�rr Depth � Set in overs¢e hole? Mnualar space inAialy grouled? <br /> � S /��� � <br /> �,,,�y� ,� � ��� � in.trom � to.�_�tS.L n. O ves No ❑ves ❑No ❑un�cnown <br />�� .�� :' ; . i..� <br /> PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑�es ❑No ❑Unknown <br /> Davi�. Dunn <br /> Property owner's madlrg address It diHerent than well locatlon address indicated above. in.from to fl. ❑ Yes ❑No ❑�� ❑No ❑UNvawn <br /> SCREEWOPEN HOLE � <br /> � �/�f <br /> Screen from rl ���to /�� ft. Open Hole from lo fl. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fiil ❑No Obstruction <br /> WeN owneYs meilirp address if diflerent ihan property owner's address inCicated above. Type Ot ObStrucNions(DBSCribe) -f/f f�¢`�t ������� 4'� Y�J�'!/!�'7 <br /> Obstrudions removed? Yes ❑ No Describe <br /> PUMP /' <br /> 7ype �(i1`' 1_'ti�?�:i <br />' (iEOLO(i1CAL MATERIAL COLOR HARDNESS OF FROM TO Remrned ❑ Not Present ❑ Other <br /> FORMATION <br /> tl rat krawn,i�EiceN estirneted formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASIN('AND BORE IIOLE: <br /> -. . No Annular Space Exits <br /> ...+ ,- ..�� ' ) /`�iJ . <br /> ❑ Annular space grouled with tremie pipe <br /> -- �❑ Casing PeAoration/Removal <br />� in.from to it. ❑ PeAorated ❑ Rertared <br /> in.from to h. ❑ Perfaated ❑ Renwred <br /> Type of perforaror a <br /> ❑ OMer <br /> GROUTING MATERIAL(S) <br /> h <br /> Grouting Matenal �C�``r�%('�,��f;�L��m � to �•.'f. p, Yerds ��,, bsgn . <br /> from to R yards beps <br /> hom to M. yards baps <br /> from to_ IL yards beps <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How man�It <br /> L�CENSEO OR REGISTERED CONTRACTOR CERTIFICATION <br /> � ;6--E;����"��"'„'_'� This well w bonng w8s sealed in acoordence with Minnesote Fules,Chapter 1725. The iraorrt�ation confained'n tlrs�apat is <br /> true to ifie best of my knowledge. <br /> ��'��� � 1 1999 ncsr� S i•UDULk WELL DkII.L�.IVG cc�. , rc�c. ��t�i�� <br /> conhacror eusiness Marne Licenss o.Reprs��aean r.o. <br /> e;i; ti „� ;.�;:,,.,.`, :, - '=' <br /> 4.,, r� ��%�� � �- � <br /> _ R. <br /> ed epresenranve signefwe oare <br /> .� � <br /> �, l. <br /> LOCALCOPY <br /> H 141571 �,�°'Pe,� ;,�w°"°`�;,� <br /> HE-01434-0.3 �R <br />