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MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring �����Q � <br /> WELL OR BORING LOCATION �yELL AND BORING SEALING RECORD Sealing No. �H p <br /> Counry Name � -- <br /> Minnesota Unique Well No. � — -- � <br /> Minnesota Statutes.Chapter 1031 or W-series No. <br /> p...w aw�x na k�ow�,� <br /> Township Name Township No Range No Section No. Fraction�sm �Iq� Date Sealed Date Well or Boring Constructetl <br /> 4rano il$ 23 �_ �1-�40� < <br /> Numencal Streel Address or Rre Number and Gry of Well or Baing Location +y� � �j f <br /> ��� ra�,.�� , pL�a� ��,� ��,Q�O� y�g Depth Before Seal�ng I ISO fl Original Depih / f`� h <br /> VL� VE# i1L7 <br /> Show exact Ixation of N•ell or boring L't,9 A t Sketch map of well or bonnq �1qUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". >>J��' location, showing property ��Single Ayuifer ❑ Mulhaquifer <br /> lines,roads,and buildings. <br /> ry WELVBORING Measured ❑ Estimated <br /> . � � � � , �Water Supply Well ❑Monit.Well _ / <br /> �- -�-- --;-- --� �� ' <br /> r'.. " � ❑ Env.Boie Hole ❑Other _ _=�,,;�ry. �below <br /> ❑above land suriace <br /> W -- - -i-- -i— —i-- E L�� `� CASING TYPE(S) <br /> r <br /> ' I I I ,_. �{ <br /> � -;-- --;-- --;-- --�- � �` �Steel ❑ Plastic ❑Tlle � Othe� <br /> }1 mile <br /> —�- ---- -,— --�— � CASING(S) <br /> Diameter Depth � Set in oversize hole? Annular space initially grouted? <br /> s e r/ <br /> �--r mea�4 M r � in �rom� to ��� ft. ❑ Ves �No ❑ �es 0 No ❑ Unknown <br /> PROPERTV OWNER'S NAME in.from to _ R. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> �► .�. <br /> Property owner's mailing a dress if aiHerent than well location address indicated above. in.from to . R. ❑ Yes ❑ No ❑ �es ❑ No ❑ Unknown <br /> SCREEWOPEN HOLE <br />, ". Screen from�to� ft. Open Hole from ro ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑ Fill ❑ No Obstruction <br /> ��)"°- .�+� <br /> Well owner's meiling etlOress if CiHerent Man property owner's address Indicated above. Type of ObStruclions(DesCribe) �1Ur� ��/`� 4" iJ S 1 <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP �g <br /> ryPe ��7� N�1/�"X� <br /> � (iEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO W Removed ❑ Not Piesent ❑ Other <br /> FORMATION <br /> . If not k{awn,indicate es�imated formatbn log from nearDy well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> • [�lo Annular Space Exists � <br /> •� f ❑Annular space grouted with tremie pipe <br /> ❑Casing PerforatioNRerrwval <br /> in.irom to ft. ❑ Pertorated ❑ Removed <br /> in.trom to fl. ❑ PeAorated ❑ Rertwved <br /> a <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material �������+�r�+�m � to�th� yards � bags <br /> from to ft. yards bags <br /> irom to ft. yerds bags <br /> from to_ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFflCULT1ES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes �No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The information contained in Mis report is <br /> true to the best ol my knowledge. <br /> Dt:Ft ,'�L!?d+o18 �ell. AL'i 11#.12g GO., I�C s 27172 <br /> Conhacror Business Name - ..r°` License a Regisfrefion ivo. <br /> : ' . � � f ti../4� <br /> s. - � .�--�` �- <br /> uthonzed Representative Signehiie Dete <br /> ���`���'�/t-�'k"v"" ��-'-�`�"�'�`+�1..�l.iY'\. <br /> , .L��:,�,. ,:{��y u �w��A A Name ol Person Sealin�'..�l or Bonng <br /> ri V V V <br />