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,. . .. _ , <br /> _ .. . ..� . ��-� ;.�. <br /> � �. . ...,,. . ,. . <br /> , . ,�,< ��� . , 4 -'� <br /> ,�m,�,,.r..,,� <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH � Minnesota Well and Boring �����'} � <br /> Counry Name WELL AND BORING SEALING RECORD°?�,�ea''"9"°. i H � <br /> lNmnesota Unique Well No. <br /> g��$+p�� Minnesota Statutes, Chapter 1031 or W-series No. <br /> �Leeve tleM tt nM known) �__ � <br /> Township Name Township No. Range No SeUion Na F�act�on�sm.-s Ig.) Date Sealed � � � �� �" ' � �- �Date Well or Bonng Constructetl <br /> ��toao 118 x3 �6 33—Q�7. <br /> Numeancal Street Adtlress or Fire Number and Giry of Well or Bonng Location � � <br /> 1.i�4 .YRiiLQ ��� A10�� V=0�0 Depth Betore Sealing � R Oriqinal Depth ft <br /> Show exact location of v.�ell or bonng ¢,a��r Sketch map of well or bonng O IFER(S) STATIC WATER LEVEL <br /> m section grid with"X". ��� Q bcahon, showing property Single Aywfer ❑ Multiaqude� <br /> lines,roads,and buildings. <br /> N WELUBOr71NG Measured ❑ Estimated <br /> ----I� �Water Supply Well ❑Monit Well <br /> � � � � <br /> �i ❑ Env.Bore Hole ❑Other _ _��R �below ❑ above�and suriace <br /> =� � <br /> t ; ' ; ' <br /> W -- - - -- - -- -- -- E CASING TYPE(S) <br /> � � � � <br /> � � � <br /> � � � <br /> �� -�-- -�-- —;-- --;— � Steel ❑ Plastic �Tile � Other <br /> t <br /> jlmile <br /> -�-- -�— --�-- --�- � CASING(S) <br /> Diameter Depth f Set in oversize hole7 Annular space initially grouted7 <br /> S �? �� �r� � �� Yes �/No Yes No Unknown <br /> �r miie� '� a.t 1 in.from to ft. ❑ � ❑ ❑ ❑ <br /> '`. . r i ,�. i,i`.�xCr�. <br /> PROPERTY OWNER'S NAME � in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> �ab�a cra�fora 473-�a�� <br /> Property owner's maihng address d diHereN than well location address indicated above in.Irom to ft. ❑ Ye5 ❑No ❑ �e5 ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> t j� ( <br /> Screen irom ifl� to_j_L� ft. Open Hole from to tt. <br /> oesraucnoNs ' <br /> _�r- WELL OWNER'S NAME �(Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction <br /> Well owner's meiling address if dilferent than property owner's atltlress indicated above. Type of Obstructions(Describe) WVC-l� ��� � 7"' f^�Tf� ��^-./C,.� <br /> Obstruclions removed? Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO � Aemoved ot Present ❑ Other <br /> FORMATIOH <br /> If not known,irWicate estimated formation 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 /> � �` � <br /> ❑Annular space grouted with tremie pipe <br /> (�, ❑Casing Perforation/Removal <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> in.from �p h. ❑ Perforated ❑ Removed <br /> Type of pertorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> .. / <br /> i � Grouting Matenal from � to�� ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to_ ft. ya�ds bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORIITfiS <br /> -0ther unsealed and unused well or boring on property? ❑Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> � � This well or boring;was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation contained in this repoA is <br /> true to the best o4my knowledge. <br /> i�a Stodola t1ei1 Dri12i� Co., Inc. 2719x <br /> Contractor Business Name � License w Registration I'ro. � <br /> f <br /> �� <br /> �� . .,.,/' �.� <br /> r <br /> o R presentafive Sign Dafe <br /> ��, .. „._.... <br /> ``�.a.�-„-„-.. �,,��. <br /> ,4�q��,� �1��,� w �/R�A� Name ol Person eling Well a Bonng <br /> H 1 v x ,% <br />