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WELL OR BORING LOCAnON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring j ������ �
<br /> WELL AND BORING SEALING RECORD sea���9 No. i H _
<br /> co�nry Name Minnesota Unique Weli No. I --
<br /> r� v. p �y� Minnesota Statutes.Chapter 1031 or W-series No. II �
<br /> .•�y�.i y�y�rJ �S �Leeve tlank M iw�keawn) L_
<br /> Township Name ' Township No. Range No SecLon No. Fracuon(sm.-►Ig.) Date Sealed Date Well or Bonng Constructed
<br /> f?rona 1 1� � �4�.f �-1'd'WUV� ?6!�� �..✓
<br /> Numerical S(reet Adtlress or Fire Number and Cay of Well oi Bonng�ocalion 1 /.+� J
<br />� ���{.i �•i �f"S_�[� !�r� �[��']�,1 Depth Before Sealing ��`�' _n Onginal Depth �`^G� tt
<br /> Show exact locatwn of N•ell or bonng Sketch map ol well or bonng AOUIFER(S) STATIC WATER LEVEL
<br /> in sec6on grid wrth"X". location. showing property � Single Aywter ❑ MulUaqwler
<br /> lines,roads,and buildings. �
<br /> �� N WELUBORING �f�Aeasured ❑ Est�mated
<br /> , .....__..�_--._�_. ..
<br /> ; , � � � � ( ater Suppiy Well ❑Monit Well r
<br /> _- - - -_ - _ , � ]�EVnv Bore Hole ❑Other _ __��._ft �below ❑ above land surface
<br /> W --i-- E ' ._...,,,,,..,,,_,.,_,,,,__. CASINGTYPE(S)
<br /> � � � � t
<br /> -;-- -;-- -;-- -�- � [�6teel � Plastic �Tile � Other
<br /> ,\
<br /> � � � � ylmile „�v CASING(S)
<br /> -�-- -�-- -1-- --�- I
<br /> � Diameter Depth r Set in oversize hole� Annular space initially grouted?
<br /> S � /�
<br /> �r mrie� � ,V � ._�_ in.irom�S.L to��fl. ❑ Yes �No ❑ �es ❑ No ❑ Unknown
<br /> c :. ;�r'.;� �J�"
<br /> PROPERTV OWNER'S NAME in.trom to R. ❑ Yes ❑ No ❑ �es ❑ No ❑ Unknown
<br /> t � :-f:
<br /> P�operty owner's mailing addr ss d Alflerent ihan well locat�on address indicated above. m.from to R. ❑ Yes ❑ No ❑ �es ❑No ❑ Unknown
<br /> ��-#)�t F I e�r i d a 1'!0� SCREEWOPEN HOLE
<br /> C,�'����� ���'w 'rj�}�}2� Screen from_��to�'ft. Open Hole from to 8.
<br /> OBSTRUCTIONS
<br /> WELL OWNER'S NAME r-,,`,�;r' 1 '� �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obsiruction
<br /> .. i�. ���� � �. �.....
<br /> � /E,�- � f
<br /> Well owner's mailing adCress if tliHeient than propeAy owner's atldress indicat above. Type of Obstructions(Describe) +���Jr t"� �' -'-��"� �� `� �-� --
<br /> ''' `r
<br /> � ��:7 1'•� . , � !:_' J ,
<br /> � . Obstructions removed? �es ❑ No Describe
<br /> /,,.1 / ��4 ` . ��` PUMP
<br /> \
<br /> � � �l.,i {�l(� � � � , . �.
<br /> 4 T
<br /> _..� `���� TYPe f�--�^�t �a .�i
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO emoved ❑ Not Present ❑ Other
<br /> FORMATION
<br /> If not known,indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
<br /> : ,� �o Annular Space Exists
<br /> � -�-� ` , ❑Annular space grouted with tremie pipe
<br /> r ❑Casing Perforation/Removal
<br /> in.from to ft. ❑ FeAorated ❑ Removed
<br /> in.irom ro R. ❑ PeAorated ❑ Removed
<br /> Type of perforator
<br /> ❑ Other
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> .r f�� �� ,�
<br /> r'A r`"' � t,
<br /> Grouting Material �f�_ , ��_ odAr`� � to�'t� fl. yards � bags
<br /> from to R. yards bags
<br /> irom to ft. yards begs
<br /> from to__ R. yards bags
<br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS
<br /> Other unsealed and unused well or boring on property? ❑Yes o How many?
<br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
<br /> This well or bonng was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation contained in this report is
<br /> true to the best of my knowledge.
<br /> �G€I it[3Cl{�Ic� 4-7L�i i4C"! t � ?1'�:" Crl. ' • �'�� ��
<br /> Contractor Business Name -� ��—SLicense or Regishetlon I'ro.
<br /> r�:� �' �f.�'�_ �.:� :, A;
<br /> qY�z�Bd presentative Signatuie i Date
<br /> �,/
<br /> `: �^�-
<br /> _� ,l.
<br /> ��., . _._.L .,*:. +„_
<br /> ������ Name ol Person Sealing Well or Bonng
<br /> LOCALCOPY H
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