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. <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring A ����A � <br /> ELL OR BORING LOCATION .__ S@ellfl9 NO. �I H 1 � <br /> Counry Name WELL AND BORING SEALING RECORD M;��esota u��q�e we��No. �------- � —�--� <br /> IJ j Mmnesota Statutes.Chapter 1031 or W-series No. � I <br /> Api.�pQ�l� 0.aev.dwcnnakrownl i _ __. ._ �J <br /> Township Name Township No j Fange No Section No. FracUon(sm.-s Ig.) Date Sealed Date Well or Bonng Consiruaed <br /> x r 7 ,. ,. <br /> lrl�/oi �u.�x� <br /> Numencal Street Address or Fire Number and City of Well or Boring Locauon <br /> �a�� �2�� �igb�o�d �� �r �Before Sealing S� _H. Onginal Depth_ ��_.____n <br /> Show exact location o�N�ell or boring Sketch map of welt or bonng AOUIFEH(S) STATIC WATER LEVEL <br /> in section grid with"X". „ / location, showing property Single Aywter ❑ Multiaquiter <br /> �f� � lines,roads,and bwldings. <br /> N �AwwV WELUBORING Measured ❑ Estimated <br /> jn f7-Waler Suppiy Well ❑MONt.Well <br /> "• ❑ Env.Bore Hole ❑Other �tl�fl. .a]below ❑ above land surtace <br /> W --�- - -- - -- --i-' E CASING TYPE(S) <br /> ' � ' � <br /> --�- -i-- -i-- --�-- � Steel � Plastic �Tile �Other <br /> ylmile <br /> --�- -�-- -�-- --i-- � _ CASING(S) . <br /> Diameter Depth Set in overs¢e hole? Annular space initially grouted? <br /> S <br /> �t mi�e� � in.from� to�_ fl. ❑ �es �No ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> Property owner's mailing address if dlife�ent than well loca6on address indicated above. in.from to k. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> Screen fron�y�to_�.� ft. Open Hole from to tt. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction <br /> Well owners meiiing a0dress if difierent than property owner's addiess indicatad above. Type of Obstructions(Describe) pa pS ��d „��� <br /> Obstructions removed? $� Yes ❑ No Describe <br /> PUMP <br /> TYPe,�$� <br /> GEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO Aemoved ❑ Not Present ❑ Other <br /> FORMATION <br /> If rat krawn,iMicate estimated formatbn log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists <br /> Dr i f t ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to R. ❑ PeAorated ❑ Removed <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> Type ot peAoraror <br /> ❑ Omer <br /> GROUTING MATERIAL(Sj (One bag of cement=94 Ibs.,one bag of bentonite=SO lbs.) <br /> Grouting Material �.�,.�— from _s�.,� !o_ _fL__._ N. yards _,�___ bags <br /> __ from to ft. yards bags <br /> from ro fl. yards begs <br /> from to__ fl. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property7 ❑Yes x]No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> E This wel!or boong was sealac!�o a�ocrd2nce with Minnesota Rules,Chapter 4725. The information contained in this raoort is <br /> � � true to the best of my knowledge. — <br /> 8ES We�l Driilit�g 27276 <br /> Gontracror Business Name License or Registrefion!':�. <br /> ,��. I1 1���: �- ��- c.� 1 <br /> . Aufhonzed Representafive Signatu Dafe � <br /> �ames Lea - _ <br /> LOCAL COPY u������/� Name ol Person Sealing Well orBonng " �� � <br /> r� � <br />