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_ __ __ _� � <br /> e WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring � w �/���� � <br /> ` ---- WELL AND BORING SEALING RECORD sear�9 rvo. i H 1 ` _ <br /> j Cou�ry Name Minnesota Unique Well No. <br /> ; Mmnesota Statutes,Chapter 1031 or W-series No. I <br /> Henaepin 0.�.mmc n�a knownl __. _ �J <br /> ' Township Name I,Townsmp No F na ge No Secnon Na Fract�on�sm.-s Ig.) Date Sealed Date Well or Boring Consiruded <br /> ' rono � 1 I 7 �3 f37" i��4-t�'12 <br /> Numencal Street Adtlress or fire Number and Ciry of Well or Bonng Locaiion � <br /> / <br /> _��! 8����� ���� 4��� Depih Before Sealing � fl. Original Depth�_ h� <br /> Show exact location of N-ell or boring Sketch map of well or bonnq ApUIFER(S) STATIC WATER LEVEL <br /> in section gnd wrth"X". IocaUon. showing propeny Single Ayuiter � Multiaquder <br /> Gnes,roads,and buildings. <br /> N WELUBORING �Measured ❑ Estimated <br /> .Water Supply Well ❑Monit.Well <br /> _ _ _Y_ _ __ __ __ ,,/�.��� <br /> i` ❑ Ern.Bore Hole ❑Olher _ L/'�`�"�"F R. I�below ❑ above land surface <br /> W --�- -i— -i-- --i-- E � CASING TYPE(S) <br /> � � � � <br /> � � � � <br /> —�- -;-- -;— --�-- � X�Steel � Plastic �Tile � Other <br /> Yzmile r <br /> —�- ---- -,�-- --�— � CASING�S) <br /> Dlameter Depth t Set�n oversize hole7 Annular space initially grouted7 <br /> S �. 7 /l /'� <br /> k—1 mile� _,(,��_ in from V to� R ❑Yes �No ❑ Yes ❑No ❑ Unknown <br /> � <br /> TV S NAME m.irom to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> `���. �`�,e 3�Q—�b�3 <br /> Property owner's mailing atldress il dlflerent than well location address indicated above. m.�rom to k. ❑ Ves ❑ No ❑ �es ❑No ❑ Unknown <br /> �!(/�i .aigQ�$S i!l�j�a SCREEWOPEN HOLE <br /> � ����a����a� � ����� Screen from_'�c�_���to��,R. Open Hole from to R. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �ods/Dro Pi e ( ) ❑Debris Fill <br /> p p ❑ Check Valve s ❑ ❑No Obstruction <br /> Well owners mailing addreu if AiffereM than properry owner's address indicated above. Type o(Obstruc�ions(Describe) ������� ./� 4 ��� <br /> Obstructions removed? �Yes � No Describe <br /> � PUMP �+' �'} - .. � � � � . <br /> Ty� ��� f !'�� <br /> GEOL061CAL MATERIAL COLOR HARDNESS OF FROM TO emoved ❑ Not Present ❑ Other � � �� � <br /> FORMATION <br /> It not known,indicete estimated fortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �'�Jo Annular Space Exists <br /> � �� <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.irom to ft. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ Omer <br /> _ _. --- -- ------ - ---------- <br /> . . .. - — � - � -- -- -- --"-• <br /> r Grouting Materiai �'� � �"� ��� to�'n yards __�.__ bags � <br /> f�� to R. yards bags � <br /> from to R. yards �9� <br /> from to-- �� yards ba<y-: <br /> i <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS d <br /> � � Yes No How many? ' <br /> Other unsealed and unused well or boring on property. ❑ <br /> UCENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> �� This well or bonng was sealed in eccordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> �true tc'he best o?my knowledge. <br /> Don S�odola �1eI1 �rillin�_Go., Inc. 27172 <br /> - ----- °. <br /> t —""—�--- License Or Registretion�vo. <br /> Can�ra-tor8us ��`��^'? <br /> __ � / Q� <br /> �- oere <br /> d �asentativa Signaturet� . <br /> LOCAL�OR`� H ��n�O� Name ol Person a ng Well or Bonng <br /> V <br />