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WELL OR BORING LOCATtON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Bonng i H �.4�0 7 3� <br /> WELL AND BORING SEALING RECORD Sealing No. <br /> Counry Name Minnesota Urnque No. — — <br /> Mmnesota Statutes,Chapte�1031 or W-serles�io. � <br /> I�eave dank A rw�known� <br /> Township Name Townshlp No. Range No Section No. Fracuon�sm.-s Ig.) Date Sealed Date Well or Bonng Constructea <br /> ! � .�Uv �;' <br /> Numencal Street Adtlress or Fire Number and Ciry o1 Well o�Boring Lowfion �/ / <br /> Depth Betore Sealmg f��� N. Onginal Depth �J� it. <br /> Slww exacY locatwn of w•el�or boring y* Sketch map ot well or bonng AOUIFER(S) STATIC WATER LEVEL <br /> in sectan gnd wiM'X'. ��� location, showing property Single AquAer �Multiaquder <br /> lines,roads,and bwldmgs. <br /> N � WELUBORING Measuretl ❑ Esnmated <br /> ,i ,� I Water Suppy Well ❑M«,u wen � <br /> - - - - - -- - -- ,� � �'' <br /> .� t �1` � ❑ Env_Bore Hde ❑Other �+_�R. �below ❑above land suAace <br /> W - - - - - -- --i-- E }`?- � CASING TYPE(S) <br /> � � � � � <br /> -;r- -�-- -�-- --�-- �` � Steel ❑Plaslic ❑Tile ❑Other <br /> ;�mrle;,. <br /> --�- -�-- --I-- --i-- � . ` CAStNG <br /> � Diameter Depth f Set m overs�ze hde7 Mnualar space inAialy grouted? <br /> �� <br /> �—r� � m.rrom � ro�r n. O ves �na ❑ ves p No O ur�nown <br /> PROPERTY OWNER'S NAME m.tram to fl. ❑ Yes ❑No ❑Yes ❑No ❑Unknown <br /> � <br /> Propeny owners maiNng ress il diflerent than well location address indicated above. in.ham to fl. ❑ Yes ❑No ❑�'es ❑No ❑UNuawn <br /> SCREEWOPEN HOLE R, <br /> � /j <br /> saeen rrom � l ro /r• � e. oper,r+o�e norn to x. <br /> OBS7AUCilONS <br /> WELL OWNER'S NAME R Chedc Valve(s) ❑Debns <br /> ods/Drop Pipe ❑ ❑Fill ❑No Obstniction <br /> � ...— <br /> WM ow�iefs msikg address il tlilfefent Man property owner's address indicated above. Typ6 ot Obstructions(DesC�b6)���''�'�f� �!.�/'C �`'-' . f F� <br /> Obsirucdms removed? �Yes ❑No Describe <br /> PUMP <br /> Type � <br /> (iEOL.0OICAL YATERIAL COLOR MARDNESS OF FROM TO �Removed �Not Present ❑ Other <br /> FORMATION <br /> tl na1 krawn,indiceb estimaroG tamatqn lop from nearby wen or bonng. METHOD USED TO SEAL ANNULJIR SPACE BE7'VUEEN 2 CASINGS,OR CASING AND BORE FiOLE: <br /> ._�j • r- F � '_' `4 ., No Mnular Space Exi1s <br /> Y <br /> ❑ An�ular space gauted wBh tremie pipe <br /> { ❑ Casing PBAorationlRertaval <br /> in-horn to fl. ❑ PeAaeted ❑ Renaved <br /> in-Irom to R. ❑ PeAweted ❑ Rertaved <br /> Type o(peAasbr <br /> ❑ Olher <br /> GROUTNiG MATERIAL(S) <br /> T / ,/ <br /> Gra,engMarerial itii=,�%c'"'�,+1 J/.–�.�4i6m S,� w `��� n. yards �("L bepa <br /> hom to ft. yards 6a�p <br /> hom to h. yard4 beps <br /> from M__ h. Ya�ds D�ps <br /> NEMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORMIGS <br /> Olher unsealed and inused we�a boring on propert� ❑Yes No Fbw many? <br /> LICENSED OR REGISTERED CONTAACTOR CERTIFICATION <br /> This weM w borirg vras sealed'n acoordence wilh MinnesWa Rules,Chapter 4725. The irHamation oorNained'n tlis raport is <br /> tnie to Me best d my lawwbdye. <br /> Don Stadoia W�11 Dril3ing Co. , Inc. 27I72 <br /> connado.9us:�Mame �, ,.) � Licenss w Repie6aem r••o. <br /> /" <br /> �� �.l - �jf�•� Ci�,� / . <br /> a� <br /> i-'. <br /> ..f�-i ..�i'��..,�.,.3��f"�.`�' <br /> LOCAL COPY H 3,4�O?3 ��a Seaig WeI d Bonrg <br /> HE-01434-03 �R <br />