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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I ������ � <br /> Counry Name <br /> — WELL AND BORING SEALING RECORD Minnesota Unique Well No. ICH— - � <br /> Minnesota Statutes.Chapter 1031 or W-series No. � <br /> A�nne f n �.,�.d���,k�,,,, _— --— <br /> Township Name Township No. Range No Section No. Fraction�sm.-i Ig) Date Sealed Date Well or Boring Const�uctetl <br /> �rono 11? 23 20 ' ' a 9� <br /> Numencal Street Address or Fire Number and Gry ol Well or Bonng Location r � <br /> 274d 8the1 A��'• y�(�nQ �5.7�� Depih Before Seal�ng���_R Original Depth ��� n <br /> Show exact location of N•ell or bonng Sketch map of well or boring AOUIFEH(S) STATIC WATER LEVEL <br /> m section gnd wrth"X". locahpn,.. showing property Smgle Aywfer � Mulhaqwfer <br /> �,�„�y,�lineslJo�,�ui Idings. <br /> ry -- -- ---- WELUBORING �Measured ❑ Esamated <br /> �Water Suppry Well ❑Monit.Well �h r <br /> ❑ Em.Bore Hole ❑Other �R I�below ❑ above land surface <br /> � � � � <br /> 7� <br /> � � � � .___ <br /> W --r- -�-- -'-- --'-- E CASING TYPE(S) <br /> —�- ---- -i-- --�-- � Steel � Plastic �Tile �Other <br /> }1milB �� <br /> —�- -j-- -�-- --j— � -- CASING(S) <br /> Diam ter Depth � Set in oversize hole� Annular space initially grouted? <br /> S �� /'� ����r({ <br /> �r mi�e� �`�� � in.from v' to�+L� tt. ❑ �es (�No ❑ Yes ❑No ❑ Unknown <br /> PROPERTV OWNER'S NAME in.from to fl. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> Lance Yickna - <br /> Properry owner's mailing aAdress d diHerent than well iocanon address mdicated above m.from to fl.. ❑ Ves ❑ No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN MOLE <br /> /�Q / 9 / <br /> Screen from J�3_S.�to�L� fl. Open Hole from to R. <br /> OBSTRUCTIONS <br /> WELLOWNER'SNAME . �. �'.�� ���-- ��� �Fods/Dro Pi <br /> p pe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstructiofn'� <br /> Well owner's mailing address il ditterent than property owner's address indicated above. Type of Obs�ructions(Describe)�/�[1`�/e • �=�� � • ��� <br /> Obstruclions removed? �Yes ❑ No Describe <br /> PUMP . <br /> TY� Su8 Pu�'tp <br /> GEOlO(i1CAL MATERIAL COLOR MARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> • FORMATION <br /> If rat known,iMicate eslimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OH CASING AND BORE HOLE: <br /> j � �No Annular Space Exists <br /> V <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing PeAoration/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to tt. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ omer <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) . <br /> /� /��r..�.r- f / / <br /> Grouting Matenal /������11G/`�Nom � to�3� tt. yards • � bags <br /> from to R. yards bags <br /> from to fl. yards bags <br /> irom to__ R. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property7 ❑Yes No How many? <br /> � LICENSED OR RECa1STERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation contained in Mis report is� <br /> true to the best ot my knowledge. <br /> Dan S�odola �Te21 Drillinq Co.� inc. 2' � <br /> Contrador Business Name � �lcense a Regis' <br /> ,// �� <br /> o s nt ignature,_� � <br /> � *�,,, <br /> �r'•�, '�"�"'✓`�+�`�l�+^4J��f1.— <br /> i yi:�? �S3P� u �C�V C� Name ol Person i Well or Boring <br /> fl Q �� <br />