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� _. . = <br /> � �,,... ,�.-;�.: r .,.. • . .. .., �r,;s"�'i`r' 9" ��.�,,�,f �4" ,,I"� <br /> .,.., ..,_,. <br /> , .,- <br /> �''"°' `�� <br /> .- , ;: � . �_: <br /> .. . , <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring ����C► i � <br /> WELL OR BORING LOCATION I <br /> �o��ry Name WELL AND BORING SEALING RECORD Sealing No. �H pr� <br /> Minnesota Unique Well No. <br /> �����p#Q M�nnesota Statutes, Chapter 1031 or W-series Na �— � <br /> heew denic rc�a xrow�� <br /> Township Name Township No. Range No Section No. Frad�on�sm.-►Ig.) Date Sealetl Date Well or Bormg Constructed <br /> � �ra�o i23 23 t33 ,. ,. � <br /> Numencal Street Address or Fire Number and City of Well or Bonng Location € � <br /> 600 � b=O� �„� h�.Q�� C G��(�, Depth Betore Seaiinq �� _8. Original Depth _�[.� n <br /> O D lJ .!a v <br /> Show exact location of H�ell or boring Sketch map of well or bonng ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing propeny �. Single Aywfer � MultiaquAer <br /> � lines,roads and i in <br /> N WELUBORING vleasured ❑ Estimated <br /> � �Water Supply Well ❑MoNt.Well � <br /> � ❑ Em.Bore Hole ❑Other _ __�_R �j below ❑ above land surface <br /> � <br /> W -- - - -- - -- -- -- E ��} CASING NPE�S) <br /> � � � � <br /> z � � <br /> � � � � '�l � <br /> --�- ---- -i-- --�-- 3 y.,�,` �teel � Plastic �Tile �Othe� <br /> � � � Yimi� '�'�'j" <br /> -;-- -�- -�-- --i-- � _,,,��f' ��_� CASING(S) <br /> Diamet�� Depth � Set In oversize hoie9 Annular space initially grouted? <br /> S �J� {/,!�� � <br /> �r�--i mi�e�s ''? � � in from� to�,LYL ft. ❑ Yes No ❑ Yes �No ❑ Unknown <br /> I I <br /> � PROPERTV OWNER'S NAME in.from to ft. ❑ Ves ❑No ❑ Yes ❑ No ❑ Unknown <br /> Property owner's mailing address il diflerent ihan well loca6on adtl�ess indicated above. m.from to R. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> 752b Turner Ad SCREEWOPEN HOLE <br /> Iadependenc+�, � �J�6 Li Screen from�to�5� ft Open Hole from lo R <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑�Fiyll� ❑ No Obstruction <br /> Well owrreYs mailing addreu if different than property owner's address indicatetl above. Type of ObSt�uCtionS(D05Cribe) �fI.�JI�� / ��� 7"� ��� <br /> Obstructions removed? Yes ❑ No Describe <br /> PUMP <br /> Type `^�i(,)����EJ M� <br /> GEOLOOICAL MATERIAL COLOR HARONESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not krawn,indicate estimeted formatbn log irom nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: � <br /> �o Annular Space Exists <br /> 'r� ❑Annular space grouted with tremie pipe <br /> _ ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from �o n, ❑ Pertorated ❑ Removed <br /> Type of peAoraror <br /> ❑ Othe� <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �� <br /> ��:��;�r� �' .� <br /> Grouting Material to R. yards bags <br /> from ro R. yards bags <br /> from to ft. yards bags <br /> from to—_ ft. yards bags <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 many? <br /> LICENSEO OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in eccordance with Minnesota Rules,Chapter 4725. The information contained in Mis repoR is <br /> true to the best of my knowledge. <br /> Hr�n Stodt��a Weil Dr321ing Gm., I�c. Z71.7Z <br /> Confractor Business Name -- License a Registration I'io. <br /> . c� - ;? �:� <br /> A odz e resentative Signature Oete <br /> ����1"'"y'i"'"' ����''•�Q.J.1�1^'\,.� <br /> i��f"'�d+k'_��+�'v � ������ Neme o/Person Sepl ir�Well or Bodng <br /> ` ; i <br />