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' Minnesota Well and Boring /I 2 9 —/, <br /> wEL� OR BORING LOCarioN MINNESOTA DEPARTMENT OF HEALTH Sealing No. H �} O f <br /> �oUn�Y Name WELL AND BORING SEALING RECORD M���eso�a u��qUe No. <br /> ��n Minneso�a Statutes.Chapter 103/ or W-series No. <br /> (Leave blank R not knownl <br /> To r�i ND �me _ Township No. Range No. Section Na Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br /> �Wr,�•� � or Boring Constructed <br /> 117 23 2a �,a �,4 �,� �, ;, �;� , � <br /> .' Numenr.al Street Address or Fire Number and City of Well or Bonng LocaUon ` �, r � <br /> �/� /�+,�,.,� p� LL (i i <br /> ,3VZ5 �,�Or3L;V � Ml ri�1 �� Mt� 55391 Depth Be(ore Sealing r � ft. Original Depih f Z��-� ft. <br /> Show exact location of well or boring Sketch map of well or �nng Static Water Level �Accurate <br /> in section grid with'�X��. IocaUon,showing property nes. <br /> - �-�-"'-'�rVads' nd buii ngs. ❑Approximate <br /> N <br /> � � � � � /, � <br /> -i- -i- -�- -� � , <br /> ;j�. ingle Aquifer ❑Multiaquifer �v ft � below above land surface <br /> i i i i --____! .,Y <br /> _i_ _�_ _i_ _i_ � CASING TYPE <br /> W i i i i E f <br /> � � � � T t• <br /> -r -�- -r- -r <br /> i i i i ,�.�e � '� �Steel ❑Plastic ❑Tile ❑Other <br /> i _i_ i _i_ � � ��-°' -. <br /> _ -i� i -i- � :' ' � <br /> f � ' <br /> . '..._.__.._�.. i: ,��_ �^'; . <br /> S Screen from-��= to � tt. Open Hole from to fl <br /> N—7 mi�e--� ; OBSTRUCTION/DEBRIS/FILL <br /> Obsiruction ❑Debris ❑Fill <br /> PROPERTY OWNEF'S NAME <br /> Cnthy ;1cGrarm �71-0074 __ <br /> Type of debris/obsiruction�� '������/�.� �w���` � ���-���1' <br />-�� Mailing Address if different ihan property address indicated above. ,�y(� <br /> Obstruction/Debris/Fill removed? I�fr'es ❑No <br /> PUMP <br /> �Removed ❑Not Present ❑ Other ''t�. �JU��r} <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS flF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole7 Annular space initially grouted? <br /> � It not known,indicate estimated formation log from nearby well or bonng. ' � <br /> clrifL � 12 �.��n from !� to _L!; fl ❑Yes �lo ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �,No Annular Space Exists <br /> � ❑Annular space grouted with iremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to k. ❑Perfora�ed ❑Removed <br /> in.(rom to k. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Oiher <br /> GROUTING MATERIAL <br /> � <br /> Grouting material„/d_%�''���' �`�/��t r 'irom � to ��,�t`„ ft. yards �bags <br /> from to tt yards bags <br /> � REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> } i (�� irom to ft. yards bags <br /> �� , .�NO ' '1 <br /> � � II UNSEALED WELLS AND 90HINGS <br /> - �-- ' _ �� �\��'.,L-r f j��; Other unsealed well or boring on propehy7 ❑Yes �.(Vo <br /> V <br /> "' LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chap�er 4725.The information contained in this report is <br /> irue to ihe best of my knowledge. <br /> J �on Stadola WeI1 Dri11;n� c�o., Ildc. 27172 <br /> ��� ��/ �9� Contractor Business Name License or Registration No. <br /> ^ � � �-- ��./J�'�-�"� (�..._ �1V-7'Y <br /> on ed Representahve Sgnature Date <br /> Jim Antos�son <br /> LOCAL COPY H 4 2 9 0 7 <br /> Name ol Person Sealing Well or Boring <br /> � HE01434-01 <br />