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, � <br /> �Su� (�y,S�� /�� „�(( Minnesota Well and 8oring <br /> WELL OR BORING LOCATIJi� <br /> � MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD^^���eso�a u��Q�e No. <br /> �� � Minnesota Statutes.Chaptei 703/ or W-senes No. <br /> 1Leave blank il nol knownl <br /> Township Name Township No Aange No SecUon No Fractwn�sm. �Ig.� Date Sealed Approximate Dale Well <br /> �-. •-� or Banng Cons�rucled <br /> Oror�o II7 23 2J '14 ��, '14 � - - �� , v <br /> Numencal Sireel Address or F�re Number and City of Well or Bonng location ;/ �t <br /> Depth Before Sealing �`, ft. Original Deplh ` � ft. <br /> L�on Park Ltfl BIk 6 25RX Casco Pt <br /> Show exact Iocalan ol well or bonng Sketch map of well or boring Static Water Level �Accurate <br /> m section gnd wdh�X- IocaUon.showing property hnes. <br /> �s � roads.and buildings. ❑Approximate <br /> N <br /> i � i <br /> -- -�- --- -- �- ; :/� <br /> ��Single Aquifer ❑Multiaquder fl. below above land surlace <br /> i i � i ; <br /> _i_ -�- -i_ CASING TVPE <br /> W E � .. <br /> � � � � �°! �^�^-._._... <br /> -r -,- -r- - <br /> i i �Steel ❑Plashc ❑Tile ❑Other <br /> m�k �,i , ;!��> <br /> -- - � - � ' .. _ <br /> �- -i - -i _. . ,f <br /> S Screen from �� lo ft Open Hole trom lo ft. <br /> N--t m��e—� � OBSTRUCTION/DEBRIS/FILL <br /> �^ Obstruction ❑Debns ❑Fill <br /> PROPERTV OWNER'S NAME <br /> 1�'il�e �rC3�1SOfl �Z S� fi , <br /> Type ol debns/obsiruction <br /> Maihng Address il ddferenl than propeAy address indicated above <br /> 5217 8Gth Ave l� Obsiruction/Debris/Fill removed� �Yes ❑Na <br /> PUMP <br /> Broo3clyn Park, 55443 <br /> �Removed ❑Not Presem ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO • <br /> FORMATION <br /> Diameter Depih Set in oversrze hole? Annular sp2ce�nAially grou�ed7 <br /> If not known,mdicale estimated formation log from nearby well or bonnq. � - <br /> �� -� , _ ��� L,. f � �/��in.from � to -" �-� ft. ❑Yes Q No ❑Yes ❑No ❑Unknown <br /> ..�%i. .- . ( <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from �o ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 1�No Annular Space Exists <br /> ❑Annular space grouted with iremie pipe <br /> ❑Casing Per(oralion/Removal <br /> m.from to fl. ❑Perforated ❑Removed <br /> f <br /> in.irom to fl. ❑PeAorated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> ,i; �'" ' + i <br /> Grouting materlal � � - -� "trom �- to =�fl- yards � bags <br /> from to ft yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICUITIES IN SEALING <br /> from to ft yards bags <br /> trom to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or bonng on property? ❑Yes �},No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> J A N j O 1996 This well or boring was sealed m accordance with Mmnesota Rules,Chapter 4725 The information contained in this repoA is <br /> ' irue to the best of my knowledge. <br /> ?k�n Stodo3.a tdell DrzlZir�,. Co., It�ic. 27172 <br /> Confractor Busmess Na e !%� L�cense or Reg�sVaGon No. <br /> "�"'_� <br /> .,�-'�';�/f� � ,�' / .� y� � ,� <br /> ,-�� <br /> o d RepresenfaUve Signature ' Dafe <br /> .,__.-�-"- f <br /> {.� �] % � •'�. ��: ,� .. -� ' a` <br /> ����� ■■ �� ± �7 Name o!Person Seabng Well or Bonng <br /> HE-0143a-0� <br />