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MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring +4 ��.{ �� � <br /> WELI��BOFING LOCATION S281ing NO. j H 1 1 <br /> CoUnty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> ��G=Cl11'���.Cl M�nnesota Statutes,Chapier 1031 or W-series No. �_ _ � <br /> �sew a�n ooi k�owo� <br /> To ship Name Township No. Range No Section No. FracLon�sm.-►Ig.) Date Sealed Date Well or Borirg Consiructetl <br /> �COY�O �.�� �� �? ��—��i�fs <br /> � '� ""' fui <br /> Numerical Street Address or Fhe Numbei and Cily of Well or Bormg Location „/ , ` / <br /> ��� (�$ ,A X'7.Ij �[� il r Q�0 J��i�'� Depth Belore Seal�ng �C.!% ft. Onginai Depth ��(� __n <br /> Show exad Iceafion of v.•ell or boring Sketch map of weil or bonng AOUIFER(S) STATIC WATER LEVEL <br /> in section gnd wtlh"X". locahon, showmg property "Single AyuAer ❑ Muttiaqwfer <br /> lines,roads.and buildings. <br /> N .__.____,.,__�._.o..__..._.___ WELUBORING �iMeasured ❑ Eshmated <br /> �� �Water Suppry Well ❑Monit.Wetl <br /> ' _ _ __ ' '" __ _' 4 / <br /> ��� � ❑ Env Bore Hole ❑O�her �.-•-���� ft. �below ❑ above land surtace <br /> W --�- - -- - -- -- -- E � CASING TYPE(S) <br /> � � � � <br /> � � � } <br /> .__ .. <br /> .. i i i � . ..3.,._ <br /> i <br /> -i- -;— —i— —i-- �£ i ' �'1 Steel � Plastic �Tile � Other <br /> y '.. J_ <br /> }�2RIIIB <br /> -�-- -i-- -�-- --i— � CASING(S) <br /> Diame r f Depth t Set in oversize hole� Annular space initially grouted7 <br /> 1 P /� Yes �lo ❑ Yes ❑No ❑ Unknown <br /> �i mxe—Ae f/ , �� � in.irom_.��� to� ft. ❑ <br /> � � <br /> PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑ No ❑ Ves ❑No ❑ Unknown <br /> Piope owner's mai in address if diHerem than well localion address Ind�cated above. in.from to ft. ❑ Ves ❑ No ❑ �es ❑No ❑ Unknown <br /> SCREEWOPEN MOLE <br /> r�r ^+ <br /> r � i <br /> Screen trp� ��,'�� to ��l f,�'� R. Open Hole from to k. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �No Obstruction <br /> Well ownai's maiting eddress if diflerent ihan property owner's atldress indicated above. Type ot Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> 1 <br /> GEOLOGICAL MATEHIAL COLOR HARDNESS OF FROM TO � Removed Not Present ❑ Other <br /> FORMATION <br /> It not known,indicate estimated formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � _� �'fJo Annular Space 6cists <br /> ��. <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.trom �o n. ❑ Perforated ❑ Removed <br /> in.from to h. ❑ Pertorated ❑ Removed <br /> Type of perforator <br /> " ❑ aner <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> !" ..� . P <br /> l l <br /> � Grouting Material ��!�� ���-� f��""�h� �-i to ��('C ft. yards bags <br /> 4 <br /> from to N. yards bags <br /> f�om to It. yards bags <br /> from to_ tt. yards bags <br /> REMAHKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <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 was sealed in accordance wiM Minnesota Rules,Chapter 4725. The information contained in this repoh is <br /> true to the best of my knowledge. <br /> ���n .>tc�c�a�.a ��11 ?�e�illin�;, Cc�. , Inc ?.7172 <br /> Confractor Business Name License or Registration fio. <br /> '/` . ._._�'-'-" .- ._. <br /> 1 . <br /> fy <br /> ��Authonzed Representative Signature - Dete <br /> _r <br /> 19�i 3 3 Name ol Person Sealing Well or Bonng <br /> LOCALCOPY H <br />