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WELL 011 BORIN6LOCATION <br />Minnesota Well and Boring H 4 912 b <br />MINNESOTA DEPARTMENT OF HEALTH Sealing No <br />County Name <br />WELL AND BORING SEALING RECORD Minnesota unique No — — <br />Minnesota Statutes. Chapter 1031 or Wsenes No. <br />Township Name Township No Range No <br />Secl.in N) Fracl.on Ism • lit <br />Date Sealed Appm—ate Data Wee <br />I <br />a Boring Constructed <br />141 Street Addle ss or Fire Number and City of Well or Boring Location <br />Sts �I <br />y� <br />� SS391 <br />C <br />Depth Before Se.pmy h Original <br />— Depth —� tl <br />Shoal esad kLalron of wes or bong <br />Sketch map of well c boring <br />Static Water Level ccurate <br />in section gntl wdh X <br />hor, showng proper Ines <br />N <br />roads and Id.ngs <br />LL Appos.male <br />r r <br />� 1 <br />�i��� <br />Sngb Aquifer ❑ Mulbaqer <br />/ <br />er <br />Mn�,w ,dmv.•lmd Wi <br />tr _� sace <br />CASING TYPE <br />f <br />W r r r r <br />r r r r � � • <br />^ <br />❑Steel ❑ PIASIK XTdw ❑Other <br />S. <br />i <br />Screen from -- to --- _._ fl Open Hole hum In -_�� h <br />-- f reA1 <br />--•-- <br />OBSTRUCTKMYDEBRIS/FILL <br />iruchon ❑ Debns ❑ FII <br />P/^ROOPE�RTY OWNER'S NAME <br />\KaiVl <br />_amarfe_ _ <br />-- __ ----- <br />Type of debris obstruction <br />M,, Lnq Agd....... .1 rLbeg int Ihnr. p, o(M•,+y ntkfres•. nuU..Ned <br />ntnwe <br />Obstruct* Debns FUI removed1 �Xe•. ❑ Nu <br />PUMP <br />L*4emoved ❑ Not Present ❑ 011ie, ��•��� �� <br />CASINO <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OF <br />FROM <br />TO <br />_ <br />FORMATION <br />D.amole, Depth Set .n oversee hule� Annular space nAlally groubW <br />--/L,-:,n from r" _ to V.? N ❑ Yes 01(o ❑ Yes ❑ No ❑ Unknowlift <br />_L __ <br />11 not krgwn r"Wale estimated lormatrurr log from nearby well or boring <br />142 <br />drift <br />0 <br />infrom _- to h ❑ yes ❑ No Ci Yes ❑ No ❑unknown <br />It ❑ Yes ❑ No ❑ Yes ❑ Nn, ❑ Unflurew <br />— — ---`— <br />-- <br />— <br />— <br />METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, 0" CAMO AM SORE "OLE: <br />CKo Annular Space E.usls <br />❑ Annular space grouted with Iremw pt.` <br />❑ Casing PerforatronFTerrroval <br />n Irom to --- If ❑ Perforated ❑ Film" .led <br />.n Irom to 4 ❑ Perforated ❑ Reeklved <br />Type of perforator <br />— <br />--- <br />❑ cher <br />O <br />_ <br />OROUTWO MATERIAL <br />--_-- - <br />- <br />Gmuhny malarial N� AT L f /�%L fVI Irom �_ to h <br />yards <br />from to If yards _ <br />REMARKS. SOURCE OF DATA. DIFFICULTIES IN SEALING <br />to h yards <br />.- from to _ h yards <br />UNSEALED WELLS AND IORMS <br />Olhor unsealed well or bonny oe p.,. •edy" ❑ Yes <br />LICENSED 00 REGISTERED CON7NACT011 CERTIFICATION <br />Ths well or bnru,q was seakd n t I-11, . a wdh Mnnesola Rules Chapter 4725 The informaloe rananed n the report is <br />I1.y. ro the best of my kn�owled.le <br />]� /�� T� �s <br />_ � Stodola k*U Dril11%' Co�� �ii<--. __- Z 72 <br />Bnti.ness Nan.. Ln'en a ­ Rf`grsfraf..+ No <br />1 • <br />�'t°"�°�' <br />( OCAS COPY <br />M 49125J�^ <br />N.e .• U Pf•rsrr, Sealing wen m k. ,.ny <br />HE 0143401 <br />