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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL AND BORING SEALING RECORD Sealing No. H 112 9 8 2 <br /> County Name Minnesota Unique No. <br /> ��� � Minnesota Statutes,Chapter f031 or W-series No. <br /> � (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-s IgJ Date Sealed Date Well or Boring Constructed <br /> C3noo�o 117 23 20 2�-4QI7� v 9� <br /> N�um�7erical Street Address or Fire Number and City of Well or Boring Location � � <br /> IW 75 C�3C0 � Rd� ��11� Depth Before Sealing ��� ft. Original Depth ` �� ft. <br /> Show exact location of well or boring Sketch map of well or boring A�UIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". - location, showing property ingle Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. <br /> N WELL/BORING �Measured ❑ Estimated <br /> / /, <br /> � � � � Water Supply Well ❑Monit.Well � <br /> _Y_ _Y_ __,__ __l__ � , �/� <br /> � � � � , <br /> � .� ❑ Env.Bore Hole ❑Other �,�ft. �elow ❑above land surface <br /> � � � � <br /> � I !� �' <br /> � W —�- -�-- -,— --,-- E j ,� .. CASING TYPE(S) .. <br /> � � : � <br /> i i � • � <br /> i � i i <br /> C � ' <br /> -=r- -�-- --�-- ---I-- $teel ❑ Plastic ❑Tile ❑ Other <br /> !6 mile <br /> -�-- -�-- -�-- —�-- � �. CASING <br /> � Diameter Depth � Set in oversize hole? Annualar space initially grouted? <br /> �tt"" "�" ! Q <br /> t mi�e� �� - �, in.from� to�S,L ft. ❑Yes �No ❑ Yes ❑ No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from ta ft. ❑Yes ❑No ❑Yes ❑No ❑ Unknown <br /> Property owner's mailing address if different ihan well location address indicated above. in.from to ft. ❑Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> 1��45 Iro�ood Crt SCREEN/OPEN HOLE <br /> � rL�.l�.�� J�J`TV 93T-5050 Screen from�,ro� ft. Open Hole from to ft. <br /> O BSTR UCTION/DE B R I S/FI LL <br /> WELL OWNER'S NAME Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> A �//��� I �� <br /> Well ownei's mailing address if diflerent than property owner's address indicated above. Type of Obstruction/Debris/Fill �/S.�.N�/t�� ! '� q" V�� <br /> Obstruction/Debris/Fill removed? [�Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log irom nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � No Annular Space Exits <br /> '`-�`-� � ''• � ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> � <br /> Grouting Material '� m � to�.��. ft. yards � bags <br /> from to ft. yards bags <br /> € <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unseUled well or boring on property? ❑ Yes � No <br /> LICENSED OR REGISTERED CONTRACTOR CERT ICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best ot my knowledge. <br /> �tm Stodola Well Drilii�� ce.; Znc. 27172_ <br /> Contractor Business Name License or Registration No. <br /> ------- �;�; r; <br /> .afUth .'ed R 23en�ative Signature Date <br /> � <br /> � <br /> , .; f <br /> ,., ; ti�1:`�".�,, <br /> Name oi Person Sealin�Well or Bonng `� <br /> LOCAL COPY H �. 1 � 9 8 2 <br /> HE-01434-02 10/95R <br />