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,.�'.;:..,�,,?" ,:�;•� �'�:;�: <br /> .—�":" .,. ..„ - ... ,, u. ,� ___.__ _._ <br /> WE�L OR,BORING lOCA7iON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' <br /> Counry Name <br /> WELL AND BORING SEALING RECORD Minnle ota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> c�.�e e�x a�w,ow�� <br /> Township N e Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constnicted <br /> �ra�c� li� 23 22 ' 3 '. ,. ac:� C� <br /> . <br /> C�PS Latitude degrees minutes seconds Depth Before Sealing � �f�tt. Original Depth ft. <br /> LOCATION: <br /> Longitude degrees minutes seconds pQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaqu'rfer <br /> WELLBORING Measured ❑Estimated <br /> �Water Supply Well ❑Monit.Well � <br /> 3W xac w ng ketch a o weilorboring � <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other 7�i ft. �below ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> ''t; <br /> ,� teel ❑Plastic ❑Tile ❑Other <br /> W --'r -i-- -i-- --i-- E�`ti��. WELLHEAD COMPLE710N <br /> � � � � ``��, Outside: ❑Well House Inside: ❑Basement Offset <br /> _ � � � <br /> -r- '--- -r' --�-- i 1� <br /> � 1�^� `y7'" �Pitless Adapter/Unit ❑Well Pd <br /> --�- -�-- -�-- --i-- I <br /> i � ❑Well Pit ❑Buried <br /> S <br /> �-�'"M°-�'� ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter � Depth Set in oversize hole? Annular space initially grouted? <br /> r o er's mai mg a ress i i erent than well location address indicated above � /� //�'+? <br /> � in.from�to L`1{„�ft. ❑Yes �'Na ❑Yes ❑No ❑Unknown <br /> in.f�Om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.f�Om to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> e � <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? ❑YBS ❑ NO DBSCfIbe <br /> FORMATION <br /> If not known,indicate estimated formalion log from nearby well or bonng PUMP <br /> _,�.,j Type <br /> r � f� <br /> ❑ Removed �+IVot Present ❑Other <br /> � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> I�lo Annular Space Exists ❑ Annular space grouted wi[h tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAI(S) (One bag of cement=94 Ibs.,one bag o}bentonite=50 Ibs.) <br /> ' Grouting Material�,/e�� E'zy`y.y�_�r_ from�.� to l�f�"-ft yards �� bags <br /> from to R. yards bags <br /> from to ft. 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 o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIPICATION - <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 oi my knowledge. <br /> 11on Stodola tdell DrilZin� ct�:. Inc. 271721 <br /> Contraclor Business Name f License or Registration No. <br /> i <br /> ,/ _. �.,,� %._.� ;;,: (c` <br /> e' Signa Date <br /> � � � �. `ti� <br /> 244442 � �J,: <br /> IOCAL COPY H �.�' <br /> Name ol Person Sea/ing Well or Bonng <br /> � <br />