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<br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring ������ �
<br /> WELL OR BORING LOCATION I �
<br /> WELL AND BORING SEALING RECORD M;��'e o"a u,,;q„8 we��No. �H
<br /> County �me --
<br /> j Mmnesota Sta�utes,Chapter 1031 or W-series No. � �
<br /> �Lseve tivJt M nd known)
<br /> To �,ip Name ownship o. Range No Section No. F�cUon}��m.-i,igi) Date Sealed Date Well or Boring Constructed
<br /> ' �' I'" .�tf � �
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<br /> e�ical Street Adtlress ir Number an Ciry ot, ell or Bonn oc lion ` �-
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<br /> 1 �� , p ��i'� Depth Before Seahng 1� _ft. Oriqinal Depih _ n
<br /> 1 i ,�.
<br /> Show exact IOCetiOn Ot w211 Or bOn � SkBtCh map o�well pr boring ApUIFER(S) STATIC WATER LEVEL
<br /> m section grid wrth"X'. locahon, showing property �.Single Aywfer � MWhaquifer
<br /> /_ Lnes,roads,and buildings.
<br /> N C.C�`� WELUBORING �Measured ❑ Esfimated
<br /> ��� �l Water Suppry Well ❑Monit.Weu
<br /> - - -T- -;-- --;-- r 7
<br /> Y � �
<br /> ; I I I I `` , ❑ Env.Bore Hole ❑Olher _ R. ❑ below ❑ above land suriace
<br /> ' I ' I / ';.,4:^ �l
<br /> W -�- -�-- -i-- --�— E .
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<br /> CASING TYPE(S)
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<br /> -�-- -�-- -i-- —�i-- � � eel ❑ Plastic ❑Tile � Other
<br /> 3�mile �'t+
<br /> —�- -i-- -'�-- --�-- I __._.. CASING(S)
<br /> � _ e� Diameter Depth Set in oversize hole? Annular space initially grouted7
<br /> l S �..JJ"�� � �" �.,,�
<br /> �(�—r mi�e�f, �.-�/��s4�.l;r�� in.irom `�! to�_ ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
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<br /> PROP�OWNER'S E r in.from ro fl. ❑ Ves ❑No ❑ Yes ❑No ❑ Unknown
<br /> r i t-t �.-,., :�+j�: f�
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<br /> Prope� owner's maiGng ress It diBe an well ocaGon address indicated above. in.from to k. ❑ Yes ❑No � ❑ Yes ❑No ❑ Unknown
<br /> !� t� , �� G�, �j� � SCREEWOPEN HOLE
<br /> �%�� < '� ��% `�P � Screen from_,� �•',y� to 1 x;_ h. Open Hole from to R.
<br /> . _:r; (_-,�� _�r J . , , ;. .
<br /> OBSTRUCTONS
<br /> WELL OWNER'S NAME
<br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑ Fill ❑No Obstruction
<br /> Well owner's mailirp addresa il ditterent than property owner's address mdice�ed above. Typ6 Of ObsVuctionS(DOSCrib6)
<br /> Obstructions removed? ❑Yes ❑ No Describe
<br /> PUMP !�
<br /> TYpe �?�,c(,;`i'
<br /> 6EOLOf31CAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ❑ Not Present ❑ Other
<br /> FORMATION
<br /> Ii rat krawn,indicete estlmated fortnatio�log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE MOLE:
<br /> ❑No Annular Space Exists
<br /> ❑Annular space grouted with tremie pipe
<br /> ❑Casing Perforation/Removal
<br /> in.from to ft. ❑ Perforated ❑ Rertroved
<br /> in.irom to ft. ❑ PeAorated ❑ Removed
<br /> Type oi pertorator
<br /> ❑ Other
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=SO lbs.)
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<br /> 1 /,
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<br /> Grouting Matenal ��t� v ft. .yarOs bags
<br /> from to ft. yards bags
<br /> from to h. yards bags
<br /> ,, irom to__ tt. yards bags
<br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
<br /> Other unsealed and unused well or boring on property7 ❑Yes ❑ How many?
<br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
<br /> . This well or boring was sealed in accordance wfth Minnesota Rules,Chapter 4725. The information conteined in Mis report is
<br /> true to Ihe be�st ot my kno edge.
<br /> P�:� j , �i...� j
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<br /> Conhaclo/�usiness Name ,st' ,,' License or Regi hefion 70.
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<br /> Authoirted �Signeture � „ Dare
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<br /> H ��A��O Name of Person, '� ng Well a Bonng
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