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MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring �� WELL OR BORING LOCATION I -- WELL AND BORING SEALING RECORD sea�i�g No. �H_ Counry;Name Minnesota Unique Well No. r --- ! Minnesofa Sfatutes.Chapler 1031 or W-series Na L � . -.. f; ..,:f:i'�.`/� 0.eeve denk rc na krwwn� Township Name� :'�Township No. Range No Section No. Fract'pr�Ism.-i ig.) Date Sealec�+' Date Weu or Boring Constructed l �; � �, -� � �~ ' ;J' ��G. �! ',` (�. �� .. , �Numencal Street Adtlress o�Fire Number and Gry ot Well or Bor�ng Locahon '"] � ;%,� �` Depth Before Seal�ng� R Original Depth _ft Show exact location of v,•ell or boring �Sketch map ot well or boring ApUIFER(S) STATIC WATER LEVEL in section gnd wrth"X". locauon, showing property �Single Aywter � Multiaquder lines,roads,and buildings. N WELUBORING 0 Measured ❑ Esnmated _ �� + [�Water Supply Well ❑Monit.Well - � - --� �— � 7 � �;� : ❑ Env.Bore Hole ❑Other ___ _ tt. ❑beiow ❑ above land surface -�.1 ' ! . W -- - '�-' -� i-- E -. ' . CASING TYPE(S) � . � � � � , , . • v :,. � � � % -�-- -�-- --�— —i-- �, ��Steei ❑ Plastic ❑Ti�e ❑ Other }1 mile > -�-- -�- -�-- �-i-- � CASING(S) Diameter Depth Set in oversize hole9 Annular space initially grouted7 S =-! �t mi�e� in.from to� H. ❑ �es ❑No ❑ Ves �No ❑ Unknown - PROPERTY OWNEfi'S NAME in.irom to tt. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown "/'' t _ Property�owner's ma��ng aAOress ii tliHerent ihan well locanon address intllcated above in.from to tt. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown k �� . ��i._ .� /f�,t . :- . SCREEWOPEN HOLE ; . q _- _ . . .. _� �.�� Screen from ro�'f R. Open Hole irom to fl. OBSTRUCTIONS WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction Well owner's mei�ing address if dilferent than properry owner's address indicated aDova. Type ot Obs�fuCtions(DeSCrib@) Obstructions removed? ❑ Yes ❑ No Describe PUMP TYPQ ,'..r^� _.,.y. r.: �cK_r GEOLO(i1CAL MATERIAL COLOFi HARDNESS OF fROM TO �Removed ❑ Not Present ❑ Other FORMATION If rwt known,indicate estimated formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BEIIUEEN 2 CASINGS,OR CASING AND BORE HOLE: ❑No Annular Space Exists ❑Annular space grouted with tremie pipe ❑Casi�g Perforation/Removal in.from to ft. ❑ Perforated ❑ Removed in.irom to R. ❑ Perforated ❑ Removed Type ot perforaror , ❑ Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) ♦ , .�'� ,. ; , �� ` ..� �...,` .; Grouting Matenal �f��"�-��r� irem " to fl. yards ' bags trom to tt. yards bags from to tt. yards bags from to__ ft. yards bags � REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes [�`No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or bonng was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in Mis repoA is true to the best of my knowledge. - Contractor Business Name � License or Regisfrefion I'ro. ,'.-( . .�� ,�-, r '. . . �_- Autho�zed Representafive Signature ' � Defe .'�`�r' . � (��i� f A,�`�.-�i...� LOCALCOPY H 19 7�2 8 Name ol Person Sealing Well or Bonng