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wEll OR BORiNG LOCA71oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I 1 ����+� � <br /> ry WELL AND BORING SEALING RECORD Me��e9o"a u�;q„e we��No. �H—'��` 1 <br /> Coun Name r — <br /> ��n a e i n Minnesota Statu/es,Chapter 103/ or W-series No. � I <br /> P M1.ww GeM�X�rot krrown) � _J <br /> Townshlp Name Townsh�p No. Range No. Section No. Fractwn�sm.-►Ig.) Date Seated Date Well or Boring Constructetl <br /> Qrono 117 23 20 ,�r��"�y �; � 9-18-01 <br /> Numencal S p�t,�A�O�ss or Flre Number and City of Well or Bonng Location <br /> 2773 � Point Rd� W&j�ZIIt8i kiN 553I1 DepthBeforeSeahng 72 fl OrigmalDepth n <br /> Show exact location of N•ell or bonng Sketch map of well or bonng AOUIFEH(S) STATIC WATER LEVEL� <br /> m section grid with"X". locanon, showing property Single Ayuder � MulOaquiter -�� <br /> lines,roads,and bwltl�ngs. <br /> N WFLUBORING ❑ Measured �samated <br /> _ _ tj Water Supply Well ❑Monit Well L� <br /> t ❑ Env.Bore Hole ❑Olher _ _ v tt �elow ❑ above land suAace <br /> W --�- -i-- -i-- --i— E 1 � . � CASING TYPE(S) <br /> � � � � <br /> � � � � <br /> =� -�-- --�- -i-- --�- � - * � �Steel ❑Plastic ❑Tile ❑Other <br />, }1 mik <br /> '_L' _J__ _�__ __i__ � . _ CiAS�I'I(3�5) <br /> ��� �`���' ��` Diameter Depth Set m oversize hole? Annular space initially grouted? <br /> S ��,�""" ,,_,/ <br /> �r mi�e� 2 in.irom� to� ft. ❑ Yes �lo ❑ �es ❑ No ld Unknown <br /> 7` <br /> P+1Pc.ZiI1�W�11G'T1 �l"j.C&..40I1 in.irom to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> P�operty own s madinQ address if different than well IocaGon aadress indicated above. in.from to fl. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> 2773 �`�F�J�I2t ROSt� SCREEWOPEN MOLE <br /> W$yzata, Mt�t 55311 68 72 <br /> Screen from to ft. Open Hole irom to R. <br /> OBSTRUCTONS <br /> �181118 r.1.L4'Ei Er icksoii ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �y No Obsiruction <br /> (� <br /> Well owners meiling adOress if dilferent than properry owner's atlCress indicated above. Type of Obstructions(Describe) - <br /> � Obstructions removed? ❑Yes ❑ No Describe <br /> 2773 Casco Foint PaCt PUMP <br /> " Wa�F�ata, MN 55311 .tet <br /> ; Tvve <br /> OEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> N rat krawn,indicete estimeted fortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE: <br /> �Jo Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforetion/Removal <br /> in.from to R. ❑ Pertoreted ❑ Removed <br /> - in.from to ft. ❑ Pertorated ❑ Removed <br /> Type of peAoretor <br /> ❑ Ome� <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> GroutingMaterial ��gt �'+Q�eAt from d to 7L fl. yards 1 begs <br /> irom to tt. yards bags <br /> from to ft. yards bags <br /> from to__ ft. yards begs <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS ���Q� <br /> Other unsealed and unused wetl or boring on property? ❑Yes ❑No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in eccordence with Minnesofa Rules,Chapter 4725. The information conteined in Mis report is <br /> true to the best of my knowledge. <br /> SCevehs DriZling & En�3ronenzent�2 Services $6654 <br /> Confrador Business Name License w Reyishatbn fvo. <br /> . , ``�.-.,`� �. -��.---.---_ 9-19-U1 <br /> aumorized Represenrafive signeture Dare <br /> Richard Stev��.s <br /> H A ����� Name ol Person Seelinp Wep a Bonng <br /> LOCAL CpPY i <br />