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� _ � � <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Weil and Boring ������ � <br /> WELL OR BORING LOCATION Sealing No. �H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> I�tens�epir� M�nnesota Statutes,Chaptei 1031 o�Wq�ries No. �-- — J <br />- Township Name Township No. Range No. Section No. Fraction(sm.-i Ig.) Date Seated Date Well or Bonrg Constructed <br /> '� r <br /> Numencal Street Adtlress or Fire Number and Gry of Well or Boring�ocation <br /> .-��� / ,r� i"� a <br /> Depth Before Seahng_��",l? ___ft Oriqinai Depth _��i h <br /> Show ezact locahon of v.�ell or bonng Sketch map of well or bor�ng AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". - IocaLon, showmg property ingle Aywfer ❑ Muttiaquder <br /> � Imes,roads.and buildings. �,` <br /> N � , � `� � �. WELUBORING y�measured ❑ Estimated <br /> � � � � � �� � ' ' � �Water Supply Well ❑Monit.Well <br /> -�- -i-- --�— --� , � <br /> Y �t ❑ Env.Bore Hole ❑Other _ _�f� }�, [�elow ❑ above land surtace <br /> W -�- -i-- -i-- —i— E � t"+`� CASINGTYPE(S) <br /> � � , � _- <br /> � � <br /> .� -;-- -;-- --;-- --i- � 1G�Steel � Plasfic �Tile �Other <br /> � � Ylmile T - <br /> —�- --�- -�-- --�— � �...._. CASING(S) <br /> Diameter Depth t Set m oversize hole9 Annular space initially grouted? <br /> S r♦ <br /> �r mi�e� __� in.from_�_ to_��,,.nft. ❑ Yes �/No ❑ Yes ❑ No ❑ Unknown <br /> T <br /> PROPERTV OWNER'S NAME in.irom to fl. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> 'r , + <br /> P�operty owner's maJing d ss il diHerent than well location adtlress indicaled a ove. in.from to ft. ❑ Yes ❑ NO ❑ �e5 ❑ NO ❑ Unknown <br /> J't�� P1O�i�$ AV� SCREEWOPENHOLE <br /> �st�Tr / t S`; � <br /> C���a�� �gt� J��{�y7 Screen from ��'-. to �ii1— tt Open Hole from to ft <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME � : _ � . -� Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction <br /> �;'�:_. , �? '�.. � .. � ��. . ` '� .. . � ,ry ./ <br /> Well owner's mailing address d diflerent than property owner's address indicated above.� Type 0�Obslructions(Desc�ibe)��yb,(�'� ,���r� g � <br /> Obstructions removed? es ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed �lot Present ❑ Other <br /> FORMATION <br /> If rat known,indicate estimated lormation log from nearby well o�bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �.' �. �o Annular Space Exists <br /> � r . ✓ • � <br /> i m ❑Annular space grouted with tremie pipe <br /> i ❑Casing Perforation/Removal <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> in.trom to fl. ❑ Perforated ❑ Removed <br /> Type of pertorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> , � <br /> C:� <br /> Grouting Matenal ry ��? � �� to�� tt. yards bags <br /> from to R. yards bags <br /> from to tt. yards bags <br /> from to__ R. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes o How many? <br /> � UCENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> trua to the best of my knowledge. <br /> i3on Stodola Well �ril.lin;; Co, , I�c. 27172 <br /> Contracror Business Name License or Registration fro. <br /> _., <br /> , f �/ <br /> .T..-..^"'"~� . <br /> �f' _.� ' �'. `J'' .r�r,._ �� % � <br /> /i.F'`%.., , � <br /> A�i Y ed` presenfative Signafure �Defe <br /> .. �; , � �f��,..,�,,, <br /> ������ Name ol Person Sealing Well qi Bonng <br /> LOCALCOPY H <br />