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;� <br /> . . <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH MIf1118SOtd W811 2fld BOflfl9 'I ��o��/"� � <br /> WELL AND BORING SEALING RECORD sea���9 No. i H � <br /> County Name Minnesota Unique Well No. � <br /> Hensepta M�nnesota Statutes,Chapter 7031 o�W-�erc�SnNo. <br /> N �—-- - � <br /> Township Name 'Townsh�p No�Fange No Section No. Fraction(sm -i Ig) Date Seaied Date Well or Bonng Consvucred <br /> i?COIIO 1�f ,�Z �7 ��Q�.��. <br /> Ntumerical SVeet Adtljress or Fire Number a^nd Ciry ot Well or Boring Location / � <br /> L��� � Ar� �_� VrO�d .7 J iV� Depth Before Sealing_�_� fl. Onginal Depth �l�tl <br /> Show exact location of well or boring Sketch map ot wen or bonng qpUIFER(S) STATIC WATER IEVEL <br /> in section grid with"X". locauon, showing property Single Aquifer � Multiaqwfer <br /> lines,roads,and buildings. <br /> N WELUBORING (�leasured ❑ Esamated <br /> ater Supply Well ❑Monit.Well r <br /> Env.Bore Hole ❑Other _ _�_R. [�elow ❑ above land surface <br /> W --�- -i-- -i— --i— E ` CASING TYPE(S) <br /> � -i-- -�-- -i-- --i-- � ��A Steel ❑ Plasfic ❑Tile ❑ Other <br /> yimi <br /> —�- -�-- -�— --�— � GISING�S) <br /> Diameter Depth � Set in oveisize hole? Annular space initially grouted? <br /> S 't// ,�,�r! <br /> �y,-,m;���, � m trom � �o_��.� ft. ❑ Yes ��vo ❑ Yes ❑ No ❑ Unknown <br /> �� <br /> PROPERTV OWNER'S NAME in.irom to tt. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> Property owner's mailing address A different Ihan well location address indicated above. in.�rom to R. ❑ Yes ❑No ❑ �e5 ❑No ❑ Unknown <br /> �g�� Sg a{�.��e SCREEWOPEN HOLE <br /> {�S r / <br /> Screen from_�_to�� ft. Open Hole from ro ft. <br /> OBSTRUCTIONS <br /> WELI OWNER'S NAME �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill�No Obsiruction <br /> Well owner's mailing address if diHerent than property ownefs aatlress mdicated above. Type of Obsiructions(DesCribe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOCICAL MATERIAL COIOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> If not krawn,indicate estimated fortnation log from nearby well or bonng. METMOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND 80RE HOLE: <br /> No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe � <br /> ❑Casing Perforation/Removal <br /> in.from �o ry. ❑ Perforated ❑ Removed <br /> in.from }o n. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ omer <br /> - GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) � <br /> / <br /> Grouting Material i��F� �from �_. ro� ft. yards �� bags <br /> irom to ft. yards bags <br /> from to ft. yards bags <br /> from to__ ft. yards bags <br /> REMARKS,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 /> � <br /> This well or bonng was seated in accc:rdance with Mirnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best ot my knowledge. <br /> �n Stodo2e�i�il�'.���iQ�Cc�., 2nc._.--27172 <br /> Contractor Business Name License or Registranon l:o. <br /> .�C� -,.:3�� :J�l <br /> t � epresentative Si� ture Defe <br /> £ �'`'.,`' iti�,..,.,,�,��l..�S�v"�,.. <br /> .�..._.s__ --_ _. _ <br /> LOCAL�C7 E� H 3 7 0 0 5 9 Name ol Person liqg Well or Boring <br />