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WELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12 4 5 6 4 <br /> County Name <br /> WELL AND BORING SEALING RECORD M nnlesoNa Unique No. <br /> Minnesota Statutes,Chapter f031 or W-series No. <br /> n (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Frection(sm.�Ig.) Date Sealed Date Well or Boring Cons[ructed <br /> rono 11 23 17 4�4-()fl2 /`� t�a:� �-r ? � <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location �)! � <br /> 2��� B� iew Pla�e �r�n� 5 5 39 Depth Before Sealing �L/ tt. Original Depth �y fl. <br /> Show exact location of well or boring Sketch map of well or boring Ap IFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property �ingle Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. �/ <br /> N WELL/BORING �J Measured ❑ Estimated <br /> � � Water Supply Well ❑Monit.Well / <br /> - - - - -;-- --;— /�/ <br /> � ❑ Env.Bore Hole ❑Other `"`"`���} ft. �below ❑ above land suAace <br /> W —'r-- -i-- -i-- --i— E � _"_ __ CASING TVPE(S) <br /> --�- -';"' -�-- �-�-- � Steel ❑ Plastic ❑Tile �Other <br /> %mile <br /> -_�- -�-- -�-- --1-- � CASING <br /> Diameter Depth � Set in oversize hole? Annualar space initially grouted? <br /> �L"" S "�" /� �^: <br /> �r,—r mi�e� :?� � �Y � in.from �✓ ro �� R. ❑ �es �No ❑ Yes ❑No ❑ Unknown <br /> I <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> Dan Pat 33urneice 420-9466 <br /> Property owner's mailing address if difterent than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> /., SCREEWOPEN HOLE <br /> / <br /> �� <br /> `�"� Screen from � to ��j/ ft. Open Hole from to ft. <br /> OgSTRUCTlO WDEBRIS/FILL <br /> WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill�No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of ObstructioNDebris/Fill <br /> Obstruction/Debris/Fill removed? ❑ Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed � Not Present ❑ Other <br /> FORMATION <br /> H not known,intlicate estimated tormation log trom nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ���� } �, ��J1 No Annular Space Exits <br /> `"� ���` ❑ Annular space grouted with tremie pipe <br /> i <br /> ❑ Casing PerforatioNRemoval <br /> in.from to fl. ❑ Perforated ❑ Removed <br /> in.from tp ry, ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> 1 <br /> l/-�%, ,- � �r- ^7�} �: <br /> Groutlng Material2 - �l���?``d'f'�rom � to� ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes ❑ No <br /> 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 Sbvdola vel2 Drilling Go. , Inc. 27172 <br /> Contracfor Business Name License or Registrallon No. <br /> �'r/'r.j�./f' . ���-�. ���-^'fiS_% r�..� ���� f " <br /> �Autfiorlied Representative Signature Date <br /> ;�--.-,.� i�-; ��ti.,�jy`�,,, <br /> LOCAL COPY H 12 4 5 6 4 Name o/Person Seali�}g Well or Bonng <br /> HE-01434-02 10/95R <br />