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��j <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ������ � <br /> wE��oR Bop�NG�o�AT�oN —_ WELL AND BORING SEALING RECORD Sealing No. I H <br /> Counry Name Minnesota Unique Well No. Ir — <br /> ��'��e�}Qi� M�nnesota Statutes, Chapter 103/ o�W�enes Na I - -- � <br /> L— <br /> Township Name Township No. Range No Section No. Fracuon�sm.-s Ig) Date Seaied Date Well or Bonng Consiructed <br /> Qr��o 1�? 23 08�1—flt31� <br />-� Numerical Streel Adtlress or Fue Number and Ciry of Well or Boring Locahon �1/,�t <br /> �� ��� Depih Belore Sealing i.+�F+ tt. Orlginal Depth . ?,,,,t�f, n <br />,., Show exact location of v.•ell or boring Sketch map of well or boring AO IFER(S) STATIC WATER LEVEL <br /> � .. in section grid with"X" bcahor��ho� property ingle Aywfer � Mulhaquder <br /> lines,roa �n buildings. <br /> - , N � WELUBORING [�leasured ❑ Estimated <br /> .. ., <br /> � � � � �� t�' ❑WaterSupplyWell'�lonit.Well �� <br /> � -- - - -- - -- - -- � <br /> �+ • �ry ,,b ❑ Env.Bore Hole ❑Other _ _ ft. �below ❑ above land surlace <br /> i i � i i✓ <br />... W —�- -i-- -i— --i-- E � � CASING TYPE(S) <br />-�:: � � � � ;� <br /> � � � � <br /> ��. .,:: ,. � � � � �! <br /> -�- -'-- <br /> -i— --�-- X�� �Steel �lastic �Tile �Other <br /> � I � � y�mile # . <br /> __L_ J__ _.i__ __i__ � f� CASING(S) <br /> Diameter Depth Set in oversize hole? /lnnular space initially grouted? <br /> I�—imiie—qa ��� from� to� it. ❑ Yes �vo ❑ �es ❑No ❑ Unknown <br /> i i ,'� <br /> PROPERTV OWNER'S NAME in.from to ft. ❑ Ves ❑No ❑ Yes ❑No ❑ Unknown <br /> Property ownei's mailing address if difterent than wel localion address indicated above. in.from to ft. ❑ �es ❑No ❑ Yes ❑No ❑ Unknown <br /> ��#II= ^��v �_�¢� SCREEWOPENHOLE <br /> Sx <br /> 615t? B��er 8d � Screen from_�_to� ft Open Hole from to ft. <br /> . �AIIl.''L Qti�lt A� ���Ei�3 � A� �' ossraucnoNs <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill f�lo Obstruction <br /> �� <br /> Weil owners mailing address if diflerent than properry owner's address indlcated above. TypB of Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed Not Present ❑ Other <br /> FORMATION <br /> If not known,iMicate estimated tormatbn log from nearby well a bonng. � METHODUSED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> . j • o Annular Space Exists <br /> �rt ' <br /> �`-�''�'` ��� '�� ❑Annular space grouted with tremie pipe <br /> � ❑Casing Perforation/Removal <br /> in.from �o ft. ❑ Perforated ❑ Removed <br /> in.from �a n. ❑ Perforated ❑ Remrned <br /> Type of peAorator <br /> ❑ Other <br /> a <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=501bs.) <br /> Grouting Material �om �_ ro�� ft. yards —� ba9s <br /> irom to fl. yards bags <br /> irom to h. yards bags <br /> from ta_ ri. yards bags <br /> REMAHKS,SOURCE OF DATA,DIFFICUITIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on propeAy? ❑Yes o How many? <br /> UCENSED OR HEGISTERED CONTRACTOR CERTIFICATION � <br /> � This well or boring was sealed in accordance with Minnesola Rules,Chapter 0725. The information contained in Mis report is <br /> true to the best of my knowledge. <br /> D08 Si'tOt�tflfl iri'1�11 t�rll.liif,g, CQ.�, IaC� 2�'1'�?_ <br /> � Conhacror Business Name . License a Regisfrafion Y:o. <br /> r, i,, <br /> � .r..,����� <br /> A o nt �ve ignBture � Date <br /> ..�.... .�1;��rtr� 1�`�..,.• <br /> . ���1��. ,,.�a�,� u � w�A� � Neme o!Person Seali ►Nell or Bonng <br /> �7 h � � i <br />