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WELL oR BORx1G�OCAT1pN MINNESOTA DEPAHTMENT OF HFALTH M�nnesota Well and eonng ' � ` �� ! O � <br /> CounryName WELL AND BORING SEALING RECORD SealingNo H L,�. L} _ <br /> M�nnesota Unique No. <br /> �Io.,.,e„� Minnesota StaNtes,Chapter 103/ or W-senes No. <br /> `y""�`"r ILeave Wank A nu�knownl <br /> Townshlp Name Township No- Range No- Sectbn No. Fraction(sm.i Ig.) Date Sealed Date Weii or Bonng Const.uctea <br /> Ororio 117 �i 03 FS'E '�NW � 10/Q3/00 <br /> Numencal SVeet AdOress o�Fue Numbe�aM Ciry o1 Well or Bonng Location <br /> 75 �• Depth Betore Seaiing �1 h. Orig�nal Depth N. � <br /> Show exad bcatan d Mell o/bonng Sketch map of well or bonng A�UIFER(S) STATIC WATER LEVEL <br /> in sectbn gnd wiM'X'_ bcation, showing property �Single Aquiter ❑ Multiaquiler <br /> lines,roads,and budd�ngs. <br /> ry ��v"\ 1 .,` WELL/BORING �] MeasureC ❑ EsGmated <br /> ��i <br /> �Water Supply Well ❑Monit.Well <br /> 3 ❑ Env Bore Hoie ❑other _ 1� n (1 beiow Q above�and sunace <br /> W -T- T- -T- -i-- E -J CASING TYPE�S) � � � <br /> -'r- -i-' -i-- -�-- � �`UvS� \ � <br /> ❑Steel � Plastic �Tile �Other <br /> Y nY1e <br /> --�- -+- -i-- -i-- � CASING <br /> Diameter Depth Set m overs¢e hde7 Mnualar space initially graited? <br /> �imis� V.�e.� 4 in.�rom� l0 267 tt. ❑ es ❑No ❑ ❑ s� <br /> 0 ` y Yes No U�known <br /> PROPERTY OWNER'S NAME in.from to R. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> Charles CarodeoutA <br /> Pmpeny ownpef�s�maiq addre_s,_s,1 ddFe�an1 Uwi weY lo�ation address indicated above. in.from to ry. ❑ Yes ❑No ❑ Yes �No ❑Unknown <br /> � J.JIJC) Y VJ.i�ilmlt. � <br /> SCREEWOPEN HOLE - <br /> 1030 Co�mty Road 83 � -f <br /> Screen(rom to R. Open Hole from �/ to � R. <br /> Maple Plain PRd 55359 <br /> OBSTRUCTIONS <br /> �LL o�,iaErRles"�arodecuito <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �No Obstructan <br /> wex owr�s m�iig�ddresa i1611ererw R�an propeny ownets aAaress indicateA above. rype ot obstructions(Describo) � <br /> Obstructions removed? ❑Yes ❑No Describe <br /> PUTAP <br /> ryPe G.}�r�ih1A <br /> GEOLO(i1CAL YATERIAL �,pq ��ESS OF FROM 70 p Removed ❑ Not Present ❑ Other <br /> FORMAT70N <br /> N�k���������a�� METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND 80RE HOIE: <br /> � No Annular Space Exits <br /> ❑ Annular sqace grouted with tremie pipe <br /> ❑ Casing Pertoration/Removal <br /> in.from to ft. ❑ PeAorated ❑ Rertaved <br /> _ in.from to ry. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ omer <br /> GROUTING MATERIAL(S) <br /> Grouting Material r��r fran � to�12L R. yerds � bsQs <br /> fran to ft. yards baqs <br /> from to ft. yards bags <br /> from ta__ k. yards beys <br /> R£YARKS,SOtNICE OF DATA,DIFRCULTIES NI SEALING OTHER WELLS AND BORINGS . <br /> Clther unsealed and unused well or boring on property7 ❑Yes �No How man� <br /> LICENSED OR HEGISTERED CONTRACTOR CEHTiFICATION <br /> This well w borirp was sealed in aocordance wRh Minnesota Rules.Chapter 4725. The information oontained in Vas report b <br /> true to the best ot my knowledge. <br /> T.L. Stevens We1l. C�ny 27194 <br /> Contredor Business Neme '//` L.icerrss w ReyistrsEion f+o. <br /> —t <br /> ,:�.�,1 IO/03/00 <br /> Autho�ized Representa0've Signefure DeM <br /> ,� �t'acner�Q _ <br /> IMPORTANT-FILE WITH PROPERTY H 14 9 2 4 0 Name o!Person Sea irg ep a Boring <br /> P4PERS-WELL OWNER COPY <br /> HE-01r34-03 ��p <br />