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t <br /> '� . MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ����� }� � <br /> WELL OR BORING LOCATION Sealing No. �H �} <br /> Couny Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. r -- � <br /> (i M�nnesota Sta�ures.Chapter t031 or W-series No. I <br /> �.�.e�u�a k�� L— <br />� Tow ship Name wnship No. Range No. Section No. F tion �I .) Date Sealed Date Well or Boring Constructed <br /> i:� �-� 3 ' �� v �� � ` � <br /> Numencal Street Adtlress o Number and City .f Well or Boring Location � _ <br /> .� � i �� - "���*v Depth Before Seahng n. Original Depth h <br /> �� <br /> Shaw exact Ixation of N•ell or boring Sketch map ol well or bonng ApU1FER(S) STATIC WATEH LEVEL <br /> m section gnd with"X'. locahon, showing property �Single Ayuder � MWhaquder <br /> lines,roads,antl buildings. <br /> N WELL/BORING Measured ❑ Estimated <br /> � .'�Water Supply Well ❑Monit.Well <br /> ,.,,-.r„� ❑ Env.Bore Hole ❑Other _ �',�tt. ❑ below ❑ above land surtace <br /> W --�- - -- - -- --i-- E CASING TYPE(S) <br /> , ' �,�.�:_�„ <br /> � <br /> � � � ,. <br /> ' ' -I- -,— --�— � � . �.-�`�' �Steel ❑ Plastic �Tile �Other <br /> --r - � <br /> I I }lmik { <br /> -�-- --i-- ' r X.: CASING(S) <br /> —�- ---- � � ,-:, <br /> � Dlameter Depth Set in oversize hole7 Annular space initially grouted7 <br /> � S {..3 Yes No ❑ �es ❑No ❑ Unknown <br /> �m;�� ,c �in.from to�� fl. ❑ ❑ <br /> PROPER�`,OWNE�S NAI�E m.from to R. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> �V,.• � ,y�.. . <br /> Pro owMr mai ing etltlress It differem than well Uon addre s in/d+icated above. in.hom to fl. ❑ Yes ❑No ❑ Yes ❑No ❑Unknown <br /> � / �/,f <br /> / � �� irf ��'.�� �.��i../��� SCREEWOPEN MOLE <br /> r�r T� �"" <br /> ! <br /> �/\ � � ��/� Screen from ��'� to� h. Open Hole from to fl. <br /> / <br /> " OBSTRUCTIONS <br /> WELL OWNER' NAME ❑ Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑ Fill ❑ No Obstruction <br /> Well owners mailing address it AiHerent than properry owner's address iMicated above. Type of Obstruclions(DeSCribB) <br /> Obstructions removed? ❑ Yes ❑ No Describe <br /> PUMP <br /> 1� <br /> Type `mL-+�-t..�- � <br /> (iEOL0f31CAL MATERIAL COLOR MARDNESS OF FHOM TO �`'Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> N not krawn,indicete estimeted tortnatbn log from ne�rby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ❑No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from �o ft. ❑ Pertorated ❑ Removed <br /> in.trom to R. ❑ PeAorated ❑ Rertroved <br /> Type of peAorator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) (One bag of cement=84 Ibs.,one bag of bentonite=50 Ibs.) <br /> ! � �6- �-�f,-- <br /> Grouting Matenal�_ ` ' YiC��',� to� n. <br /> from lo ft. yards <br /> irom to ft. yards bags <br /> from to_— ft. yards begs <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINCaS <br /> Other unsealed and unused well or boring on property? ❑Yes [�}No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring wes sealed in accordence with Minnesata Rules,Chapte�4725. The infortnation coMeined in Mis report is <br /> . true ro the best of my k�wledge. <br /> � /�{ � <br /> ��' / / , f rt. ' ,.y , __ <br /> �,�./ �,1;(�i /' �� c_�—�i�6 f!a /_. ) <br /> Contracfor Bus�ness Nam�e�'��'� L�cense w Reg�� <br /> ', �� '�- _...__ \. /� <br /> Authonz ignature -� �-� fe ��� <br /> . ..��.)`��r�-' J,� <br /> LOGAL COPY H 1��01�a Name ol PersKii 7ing Well or BoA� ;, ` � <br />