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�T.....�,�,.....�,�.9.�.�..� _ _ �_ wEll OR BORiNG LOCA71oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring j ��A��A � CounlyName WELL AND BORING SEALING RECORD sea''"9"°. iH__ _ 3 _L Minnesota Unique Well No. ��Ep�� Minnesota Statutes,Chapter 1031 or W-series No. (Leew Herik M not known) .. � Township Name Township No. Range No Section No. Fracuon�sm.-s Iq� Date Sealed Date Well or Boring ConsVuctea C?ltl�O i 1� 2 3 3 fs �''�A�'° �L� l�tU� �O, �063U 19 5t1►'�t Numencal Sireet Address or Fire Number and City of Well or Bonng Locahon �� a�rs�=*y n� Depth Before Sealing y�.� fl Original Depth j� tt S C�AiT3.Rtfi�ta-r A Show exact location of N•ell or boring Sketch map of well or bor�ng AOUIFER(S) STATIC WATER LEVEL in section grid with"X". locauon, showing property Single Aywfer � Multiaquifer '�j lines,roads,and buildings. N .CR WEWBORING �Measured ❑ Estimated _ _ _ __ _ __ __ __ � W Water Supply Well ❑Monit.Well C�� ❑ Ern.Bore Hole ❑Other _ __�_fl. �below ❑ above land surtace � �'� W —�- -i-- -i-- --i— E CASING TYPE(S) � � � � . � � � � --�- -�-- -�-� --��- � �� Steel ❑ Plastic �Tile �Other Yemile __�_ ��` CASING(S) -�-- -�-- —�-- � �1i Diameter Depth Set in oversae hole7 Annular space initially grouted7 � S J� Yes �No ❑ Yes ❑No ❑ Unknown im��e—ary in.irom Q to �6 fl. ❑ � Z t?�' 2 PROPERTV OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown L�ENWYN BECKSTRt� • Property owner's maihng address if tlifferent than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ �es ❑ No ❑ Unknown 2�� F�� SCREEWOPENHOLE [�1�YZ[�T�� Ij �f'j;j�� Sc�eentrom �� to �g tt. OpenHolefrom to R. OBSTRUCTIONS WELL OWNER'S NAME � Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill [�No Obstruction �� Well ownets meiling aAAress if ditterent tnan property owner's a�ress indicated above. Type of Obslructions(Describe) Obstructions removed? ❑Yes ❑ No Describe PUMP TyPe HA� FU1�IP Iiq YARL} GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other FORMATION It not known,indicete estimated fortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space 6cists CLAY �� $ ❑Annular space grouted with tremie pipe R�'� �� _Q ❑Casing Perforation/Removal in.from to tt. ❑ Pertorated ❑ Removed in.irom to n. ❑ PeAorated ❑ Removed Type of perforator ❑ Other GHOUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �arrrz.� z� o x Grouting Material _ __ from _ ro fl. yards bags from to ri. yards bags from to ft. yards bags from to__ R. yards bags REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALIHG OTHER WELLS AND BORINGS �i,��sY �,R�' i��Q ��s�i �.��,• Oth nd unused well or boring on property? ❑Yes No How many? � LICEN D EGISTERED CONTRACTOR CERTIFICATION WAT�R I,�§T�I. It�i AAc3V� td�I.1�: 1 U/1 j88 � This well or bonng was sealed in accordance with Minnesota Rules,Chapter 4725. The intormation contained in Mis report is DATE iiiATER LEV�L T.AK�3: 12() true to the best of my know�edge. e� MAP ('�E f C—] 5 l_ S r H. RF.�dNE�. & S+E�S, II�C. 71�15 S E A L� � Con trci(ress Name t"^ L�cense or Registration 170. � ..�. �r5�c�o According to MN State Regulations AuthonzedRep sen tiveSignature Date KIs'i�I�t �tCN�R'E�t3.ETN/lCEVIM HOPPL? --- :, LOCAL COPY ' ��A Name ol Person Sealing Well or Boring G