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� _ - <br /> ' wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Seai ng No. ell and Boring '„' � <br /> % CountyName WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> �� i� Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leeve Menk�not kiwwn) <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> f�ra� I17 23 10 '�� �� '�� c <br /> , <br /> GPS LatRude degrees minutes seconds <br /> LOCATION: Depth Before Sealing ��� ft. Original Depth ft. <br /> Longitude degrees minutes seconds ppU1FER(S) STATIC WATER LEVEL <br /> Numencai Street Address or Fire Number and City of Welt or Boring Location Single Aquifer ❑Multlaquifer <br /> ELLBORING �Measured ❑Estimated <br /> Water Supply Well ❑Monit.Well �� �` <br /> Show exact location of well or bonng Sketch map of well or bo'ng <br /> ' in section gnd wdh"X" location,showing prope ❑Env.Bore Hole ❑Other ft. �below ❑above land surface <br /> N lines,roads,and buildin CASING TYPE(S) <br /> � Steel ❑Plastic ❑Tile ❑Other <br /> W -�- - -- - -- -- - E f �\ WELLHEAD COMPLETION <br /> � , � J <br /> Outside: ❑Well House Inside: ❑Basement Offset <br /> _Y_ _1__ _l__ __�__ �� <br /> 1��b �p Pitless Adapter/Unit ❑Well Pit <br /> --;- -�-- -i-- --i- I ��n <br /> � ❑Well Pit ❑Buried <br /> S <br /> �—�"'�°—�' . ❑Buried <br /> _ ._.,a-�. � .� . <br /> ��.. PROt�PER�TY OWNt�E�R.'S NAME/COMPANY qN�AMLE����.�y CASING(S) �.� <br /> zi�C�� M��� �4�ft�#"'77�� Diamgtar , � � Dep�� Set in oversize hole? Annular space initially grouted? � <br /> Property owner's mailing address if diHerent than well location address indicated above /t�" /� � <br /> �_Z in.f�om t./ to ft. ❑Yes �Na ❑Yes ❑No ❑Unknown <br /> in.f�om to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.f�om to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> ; WELL OWNER'S NAMEICOMPANY NAME SCREEWOPEN HOLE <br /> ��, .^yf � ! <br /> Well owner's mailing address if different than properry owners address indicated above Screen from�[O��ft. Open Hole fron __, _tQ' _ft. <br /> oesTaucnoNs <br /> Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) �/I�1N�� ���.� � ��,iJ � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑ No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> CJ ;t`J TYPe ��,.)�-� Ql. <br /> p"� j�Removed ❑ Not Present ❑Other <br /> ;�J METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal - <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> v' �^ ��r�- � /�J�l / <br /> Grouting Material ��/�! ��,�// from � to �� 'ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Don Stc�dola Well Dri2lir� CQ, Inc. ;27172 <br /> Contractor Busines Name _._. License or Registration No. <br /> //'��'' _=%-- <br /> e epresentative Signature ` Date <br /> \,., i_" <br /> H 2�5 911 ` �--, _�._,��,.� <br /> LOCAL COPY f ��� ,�--� <br /> Name of Person Sealing Well or Boring <br />