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� <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I l�� �y <br /> Counry Name <br /> WELL AND BORING SEALING RECORD Minn1esoNa Unique Well No. L a <br /> � i� Minnesota Statufes,Chapter f031 or W-series No. <br /> ci.eew w�x n�w w�ow�� <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> Or� I 2 7 23 5 14 31 ��� �� O f� O <br /> GPS Latitude degrees minutes seconds � � <br /> LOCATION: Depth Before Sealing ft. Original Depth R. <br /> Longitude degrees minutes seconds �y�FER(S) STATiC WATER LEVEL <br /> Numerical Street Address or Fire Number and City o(Well or Boring Location J�Single Aquifer ❑Multlaquifer <br /> E UBORING Measured ❑Estimated <br /> ew �� C?ror�o 55355 �ater Supply Well ❑Monit.Well � <br /> Show exad bcation of well or boring Sketch map of well or ori <br /> in section grid with"X' location,showing pro ❑Env.Bore Hole ❑Other ft. �low ❑above land surface <br /> N lines,roads,and buil 96� CASING TYPE(S) <br /> . _. � Steel ❑Plastic ❑Tile ❑Other <br /> W —�- -i-- -i-- --i— E ' 4 .j WELLHEADCOMPLETION <br /> � � � � 1 <br /> ' A � -�� Outside: ❑Well House Inside:�if Basement Offset <br /> -=r- ---- -;-- -i-- ,¢�1-` t ! /i <br /> � �^� � ❑Pitless Adapter/Unit ❑Well Pit <br /> r ✓ <br /> _'�' '�' '�" 'i" � ` ,_ - 7 � <br /> �.� f�' � ❑Well Pit ❑Buried <br /> ��^S'a—�' i:� ' '�,� �� �Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAM CASING(S) <br /> R�t� ��ZQ t Diameter Depth / Set in oversize hole? Annular space initially grouted? <br />� Property owner's mailing address rf different than well location address indicated above �; /�'� <br /> � in.from_S.� t0 ft. ❑Yes �tJo ❑Yes ❑No ❑Unknown <br /> I1�i314 �dertmar� Rd r <br /> ��f.�,� � GCht$ in.frOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> A�3 3 J 31 <br /> in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAMEJCOMPANY NAME SCREEWOPEN HO E / <br /> f <br /> Well owner's mailing address if different than property owner's address indicated above Screen from�t0�ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br />� ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑ NO DBSCfibE <br /> FORMATION <br /> If rrot known,indicate es6mated formation log from nearby well or boring PUMP <br /> r,'"'� , , ;.j� TyPe <br /> l,J� ` <br /> � ❑ Removed �Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PerforatioNRemoval <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <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�/��—�`'t�f +�/1(C+��/from�to�h yards �. bags <br /> from to ft. yards bags <br /> from to R. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> �or� Stodols Well Uril.ling Co,. Inc. 27172 <br /> Contractor Bu iness Name -��� �� License or Registration No. <br /> -_.. � . //� �r,�� ../ ,! <br /> //f a.Y'-1 <br /> th presentativeSignatvre• Date <br /> � <br /> LOCAL COPY H ^ ,y-,-` _�'" _ S)��'e <br /> 2�^^���� Name of Person Sealing Well or Bonng � <br />