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Minnesota Well and Boring <br /> wE�L OR BORING�OCA710N MINNESOTA DEPARTMENT OF HEALTH Sealing No. � 199 <br /> CountyName WELL AND BORING SEALING RECORD^^���eso,a u���v� • <br /> M�nnesota Sta�utes.Chap�er 1031 or W-senes No. <br /> ILeave Dlank i�nol knownl <br /> Towns ip e Township No Aange No Sechon No Frection�sm. �Ig) Date Sealed Approx ate Date Well <br /> or Boring Consiructed <br /> ?1L� ��� G.7 �la �la �i4 �-�G . �ry r <br /> Numencal Slreel Address or Fire Number and Cay ol Well or Bormg Localwn / <br /> TS�� T�t Q�� �+ , � �S Depth Before Sealing f�� f ft Original Depth �f� �t <br /> L[) \A lJt71 <br /> Show exac�localron ol well or bonng -.�� Skelch map of well or bonng StaUc Water Level Accurate <br /> in section grid wilh��X�- �ocation.showing p�operty lines. <br /> roads.and bwid�C9s ❑Approx�ma�e <br /> N - <br /> -- -;- -;- -- .,,� <br /> r <br /> � � . � Single Aqwfer ❑Multiaquder �a fl. � below above land suAace <br /> i i • <br /> _i_ _�_ -i_ � � CASING TYPE <br /> W E <br /> � � � <br /> - -,- -r- <br /> i i i � Steel ❑Plas�iC ❑Tile ❑O�her <br /> mik...� <br /> __ "' _!' _i_ � '.._.,J � .. ! � <br /> i <br /> �/,t� <br /> S �,.t Screen Irom �'i� 10 �� fl. Open Hole from to ft <br /> �—7 mrle--� OBSTRUCTION/DEBRIS/FILL <br /> �`� <br /> �Obsiruction ❑Debns ❑Fill <br /> PROPEHTV OWNER'S NAME <br /> / 1:, f9 <br /> L��OIk3rd G 'r �"'�'' �ft1�F/=' 'p��' ¢ j�'' /?'1�^- <br /> Type of debns/obstruction .� � { U / <br /> MaJing Address�d,d�i.ff,e,�reynt,i.h,Tan,�,propeAy address i�.nd�cated above <br /> .Attn: 4'L31..��LC�� ��.gc.� ObstrucUon/Debns/Fill removed7 Ves ❑No <br /> C/O 1X3lC�WO� ��IO�C PUMP <br /> 12I2 �layzata Blvd �. y�/� <br /> Wa�syt•d� 1'lL�l ��'JCJl At�s .Wb ti{,���.�.3 Removed ❑Not Present ❑ Other ,„7��� �U�!'J <br /> �'.r. i�2�.Y1 <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depih Set in overs¢e hole? Annular space ini�ially grou�ed9 <br /> If not known.mdicate estimated formahon log from nearby well or bormg. � <br /> �l <br /> in.from �to //��it. ❑Yes �lo ❑Yes ❑No ❑Unknown <br /> Drift " <br /> in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.trom to R. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists <br /> ❑Annular space grou�ed with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to R. ❑Perforated ❑Removed <br /> in.from �o n. ❑Perforaled ❑Removed <br /> Type of perforator <br /> ❑O�her <br /> GROUTING MATERIAL <br /> / <br /> Grouting matenal w lf��1L.U�from �_to �/2 ft. yards �_bags <br /> from ro tt. yards bags <br /> REMAHKS,SOURCE Of DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> from to ft yards bags <br /> UNSEALEO WELLS AND BORINGS <br /> Other unsealed well or bonng on property7 ❑Yes o <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed m accordance with Minnesola Rules,Chapter 4725.The information contamed in this report is <br /> true to ihe best of my knowledge. <br /> Dot3 Stodol�st��ll Dri.Il�n� ^.n , I"�c- �t�� <br /> Conhactor Busmess Name L�cense or Regrsfrabon No <br /> �` <br /> � 9-26-95 <br /> _-�;,, �� �, <br /> / d Epresentadve Sigi�at Date <br /> Jl.r3 �I1�Oi3SOi1 <br /> �,�'�„�'� � Name ol Person Sealing Well or Bonng <br /> HE-0�434-Ot <br />