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� '-- . � � .=:z . - �.,. . . , <br /> , .. �.. f... :.. -.,,,.... <br /> wELI OR BOR�NG LOCATION MINNESOTA DEPARTMENT OF HFALTH M�nnesota Well and Bonng rH l4 5 414 � <br /> ry WELL AND BORING SEALING RECORD Sealing No. <br /> Coun Name Minneso;a Unique No. � <br /> H�nr���in Minnesota Statutes,Chapier 1031 or W-series No. <br /> � (Leave Dlank A nol known) <br /> Township Name Township No. Range No. Section No. Frac6on(sm.-►Ig.) Date Sealed Date Well or Boring ConstructeA <br /> flr�ne� i17 23 5 � „ 9/24/9F� <br /> Numencal Street Address or Pire Number and Ciry of Well or Bonng Lceation <br /> 2 q� Cj��y�1 fL?� pV Q Depth Before Seal�ng o� _N Original Depih 85 fl <br /> Show exact loca6on of w�ell or borirg Sketch map ot well or bonng ApU1FER�S) STATIC WATER LEVEL <br /> in section gnd with'X'. bcation, showing property ingle Aqurfer ❑ Mul�iaquAer <br /> lines,roads,and bwldi s. <br /> N WELUBORING �Aeasured ❑ Estimated <br /> �y []QNater Supply Well ❑Monit.Well <br /> r T � � � �.ti,. <br /> ; ' � ; w� t y` ❑ Env.Bo�e Hole ❑Other _ �� ry. �J pe� ❑apove land su�ace <br /> W --�- -�-- -'-- -'-- E �c�`' - CASING TVPE�S) <br /> -�-- -i-- -i-- -�-- � ^ '�1 [�Steel ❑ Plasfic ❑Tile �Other <br /> � , � um ' <br /> —�- -�-- -�-- -�-- � �� `�. CASING <br /> � Diameter De ih Set in oversize hde7 ? <br /> S � ���� � P Annualar space Irntially grouted <br /> �(r—r rrw� /f `. 1 in.from� to� fl. ❑Yes ;]No ❑�es ❑No ❑Unknown <br /> I �� <br /> PHOPERTV OWNER'S NAME in.irom to R. ❑ Yes ❑No ❑Yes ❑No ❑Unknown <br /> Hark L� r�on <br /> Propeity owners mailing aAdress A dillerent Man well locatwn address inA�cated above. in.irom to ft. ❑ Yes ❑No ❑V� ❑No ❑Unknown <br /> SCREEWOPEN HOLE <br /> Screen from�1 � to �J fl. Open Hole from to R. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑ Fill ❑No Obstrudpn <br /> WeN owr�eYs mairg aAEress il dAb�errt then properry owners adlrass irWicated above. Type of Obstructions(Describe) �i� d Tid j 2 t <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP <br /> Tr�^i et <br /> GEOLOOICAL MATERIAL COLOR HAHDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> tl ral knorm,inditale e�tls01o1mauon bp from neaiby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE MOLE: <br /> �No Annular Space Exits <br /> �r�1 t ❑ Annular <br /> space grouted with tremie pipe <br /> ❑ Casing PertoratioNRemoval <br /> in.from to ft. ❑ PeAwated ❑ Rertioved <br /> in.trom to ft. ❑ PeAaa�ed ❑ Renwved <br /> Type oi peAorator <br /> ❑ omer <br /> GROUTING MATERIAL(S) <br /> GroutlngMatenal ��'���'d�u trom � to V 1t. yards � bags <br /> trom to tl. yards bags <br /> from ta .. . R. yarida bags <br /> from to__ tt. yards begs <br /> REMARKS,SOINiCE OF DATA,DIFFICULTES RI SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes_.�Mo How many? <br /> UCENSED OR REGISTERED CONTRACTOR CERTiFICATION <br /> This well or bonng was sealed in accordance wiM Minnesota Rules,Chapte'r'1725. The�Aortr�atim�ed in Mis repoA ie <br /> true to the best of my knowledge. _ <br /> �ES Well �riliiei� 17�76 <br /> Conhacror Business Name L�or Rep'sYrabon�'. <br /> r---=� �•. `� � � <br /> • y�" <br /> rif %- _ <br /> A ed Represenfative igneture OWs <br /> Jaa�es L�a -,� <br /> LOCAL COPY H 14 5 414 ��oI Person Seali�Well or Bonng <br /> HE-0143403 2/97 R <br />