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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Bonng � � <br /> WELLORBORINGLOCA710N yyELL AND BORING SEALING RECORD SeaungNo. H 1415�J� 1�- <br /> Counry Name Mmnesota Urnque No- — <br /> �$i1i�2�?@n Mmnesota Statutes,Chaprer 1031 or W-serles►vo. r-' '" � ' r� 7 <br /> Ileave blank A no�krawn� ��' <br /> Township Name Township No. Raryge No. Section No. Fracbon�sm.-►iq.) Date Sealed Date Well or Bonrg Constmctetl � <br /> C�r.onc� 1 i 8 13 3 6 ... <br /> H � r, <br /> Numencal Street Address o�Fire Number and Gty of Well or Bormg Location � � . <br /> �7� N(�gr.�i Fernczale Raad, CrQ�7Q Depth Before Sealing � N. Onqinal Depth_��Z h. <br /> Show exad locatlon of w�ell or boring Sketch m qof well o�oring AOUIFEF�S) STATIC WATER LEVEL <br /> io section gnd wrth'X'. J[��(�'� locati�flowing p perty Single Aywfer � Multiaqwfer <br /> linba; ads,and buil nf�g. <br /> ry � rC WELUBORING Measured ❑Estimated <br /> � Water Supply Well ❑Monit.Well / <br /> - - - - - -- - — ' � �Q � <br /> � � � � � <br /> � ❑ Env.Bore Hole ❑Other _ ry. pe�pN, ❑apa,e IarM yiAace <br /> � � � � , <br /> , �f <br /> W --�- - -- - -- --'-- E � CASING TVPE(S) <br /> � � <br /> � � ; ; <br /> � � � � � ti. <br /> ' 'd : <br /> —�� � � � i r <br /> ' '�-' -i'- --�-- � } .�.� Steel ❑ Plastic �Tile ❑Other <br /> !�mrle ; $ � t_ <br /> � � ^' CASING <br /> —�- -�-- -i-- --�-- i . , <br /> � �-�"' � Diameter Depth � Set m oversize hde? Ar�alar space nypally yrqAeC? <br /> �t mxe—�w t_.,_.._.._......� ,,� �/m.irom� to� R. ❑Ves �No ❑Yes ❑No ❑Unkrwwn � <br /> I f-� <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑Yes ❑No ❑l�Yuw� <br /> ruce Htren Ha�neS <br /> P� er's mailing address ii diHerent than well location address indicated above. in.from to R. ❑Ves ❑� ❑r� ❑� ❑��� <br /> ��i� S. BYC1t3C�W�aY SCREEWOPEN HOLE �I� <br /> Wayzat�, MN 55�9� /c� ' i <br /> Screen from to ft. Open Hde from�b�� R. <br /> OBSTRUCTIONS <br /> WELL ONMER'S NAME <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑ Fill No Obstn�ction <br /> WeN ownels msiling address it dilferent Man p/operty owner's address indicated above. Type of Obslrudions(Describe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> (iEOLO(i1CAL MATERUL COLOR HARDNESS OF FROM TO � Removed Not Present ❑ Other <br /> FORMATION <br /> tl na krawn,w�dicete estimated formauon log Irom nearDy well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASNK'AIO BORE HOLE: � <br /> ,-,.f; �1..=+ _ � No Annular Space Exits <br /> r�,� ... . '- <�� <br /> �"��`�''''� / / �`� �' ❑ Annular space grouted with tremie pipe <br /> ,':i� ��,� 1,- � ❑ Casing PeAoratioNRemoval � <br /> ,c..,.. -•.�.,� ,_i I� <br /> � �� � � � in.from to fl. ❑ PeAaaled ❑ Renprsd <br /> ,;:..t..,-_ ^..3� .:> y_1 �l.= <br /> _ ., ',; <br /> �>-'`� �%� : a �� .+�.• /� l/�j 1 f'r in.from to iL ❑ Parbwbd ❑ Ranwved <br /> L 1�-.:. <br /> � �_.�..ctJ�r..` „_A�. M rype or perforecor <br /> ❑ Omer <br /> GROUTING MATERIAL(S) <br /> .,r �L �,,,.' /�j ��� � <br /> Grouting Material!{�/r�L f'�j/•!�an v ro 5 '� 1l. yardg?� trps <br /> from to R yards baps <br /> irom m R yar�ds b�ps <br /> from to R yardy bsp� <br /> REMARKS,SOURCE OF DATA,dFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on praperty? ❑Yes No How ma� <br /> UCENSED OH REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota RWes,Chapter 4725. The irrorma0m oontained in trs�apat is <br /> true to the best of my knowledge. <br /> DtJN STf3UUL�, WELL 8lRILLIIdG CO. , INC. 271 I z <br /> Conhactor Business Name �' . Lioses or Repsha�pn fio. <br /> J <br /> Y /7!/�, �1' / �V <br /> .� /� j <br /> u epresenfative Signature DWs <br /> S ,,,,1,.,r.. i„�,.�.�~". <br /> LOCAL COPY H ����O� Name ol Person hg Well a Boring � <br /> -01030-03 2/87 R <br />