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2 � <br /> � <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring Ll ������ � <br /> WEI�OH BORING LOCATION $@811f1J NO. I fl <br /> Counry Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. -- <br /> ��I�D�pin Minnesota Statutes.Chapter 1031 0�W��senes No. <br /> �----- � <br /> Townshlp Name Township No. Range No Section No. FracUon�sm -i Ig) Date Sealed Date Well or Boring Constructetl <br /> f�t@ifa �Y� �� �� ��"`��.Z <br /> Numger+ic�al Streget AddQress or Fire NumTber and Ciry of Well or Bonnq Locat�on �ry <br /> �JL� i7 r7�0�� YT.� �����' Depth Betore Seal�ng Jl��.� _ft Originai Depth .f�r h� <br /> Show exact locatwn of N-ell or boring Sketch map ol well or boring AOUIFER�S) STATIC WATER LEVEL <br /> m section grid wdh"X". bcaUon,�Bying�property Single Aywfer ❑ Multiaquifer <br /> lines,roa �n�6�ildings. <br /> � N WELUBORING ( �Measured ❑ Esumated <br /> ��� � � � � �� ��� ❑Water Suppty Well�Monit.Well � <br /> '�' — - - -- --i-- --�-- �j <br /> � I �i� ,��� ❑ Em.Bore Hole ❑Other _ _. + N. �below ❑ above land surtace <br /> � <br /> y,� -- - - -- -i-- --�— E �� • �kIO CASING TYPE�S) <br /> r � <br /> � � � � �, <br /> � <br /> � � � � <br /> —�- -i-- -i-- --;— a� ❑Steel [�lasac �Tile � Other <br /> � i � � �mile ��.j! <br /> ' ' ' ' � � CASING(S) <br /> —�- -i-- -�-- --�— <br /> Diameter Depth Set in overs¢e hole? /lnnular space initially grouted7 <br /> �l� S "�� t <br /> i mi�e� �in.Irom�,� to_�_ ft. ❑ Yes �o ❑ Yes ❑No ❑ Unknown <br /> � <br /> PROPERTV OWNER'S NAME in.irom to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Property owner's mailing address if tlitferem than well iocation address indicated above. in.from to ft. ❑ Ves ❑No ❑ Ves ❑No ❑ Unknown <br /> �t,��+ g,��.� g�„3���� SCREEWOPEN HOLE <br /> � i3 1 <br /> t� 1 +b <br /> �!,�� �$��� #�� ,� Screen trom�to ��. __ ft. Open Hole from to ft. <br /> l�T1tl8Ct�fl�f8� �T �'���l�l' � t`t� ,�' oesraucnoNs <br /> WELL OWNER'S NAME Rods/Dro Pi e <br /> ❑ p p ❑Check Valve(s) ❑ Debris ❑ Fill �No Obstruction <br /> . Well owner's mailing address if diRerent Man properry owner's address mdicated above. Type ot Obstrucli0ns(Describ8) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR MARDNESS OF FROM TO � Removed ❑ Not Present �Other <br /> FORMATION <br /> If not known,indicate estimated tormatbn log from nearby well o�bonng. METHOD USED TO SEAL ANNULAH SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �'fJo Annular Space Exists <br /> f� <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.irom ro ft. ❑ PeAorated ❑ Femoved <br /> in.irom to fl. ❑ Perforated ❑ Removed <br /> Type o�peAorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag af cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material �.{/f����om _y� to� tt. yards _� bags <br /> from to R. yards bags <br /> from to ft. yerds 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 boring was sealed in accordance wiM Minnesola Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> D4n Stodo�.a WeI� �iri��.i�g G�. , Inc. 27112 <br /> Contracror Business e , .. l License or Registrafion I'+o. <br /> �. `� - �,,j�� *✓ti.J <br /> o ed Representative Signature'' Dafe <br /> ..�'.��` �_>^.����0/'.2....►�"+i'...�a► <br /> . �4�������,� u � ��I�� � Name ol Person Seelin 1 a Boring <br /> r, h <br />