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_ - - - � MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring +� C�c�� WELL OR BORING LOCATION Sealing No. ��"� �o��ry Name ---- WELL AND BORING SEALING RECORD �v v_ Minnesota Unique Well No. I -1 ��II&�p�� M�nnesota Sfatutes. Chapte�1031 o�W-�eries No. �--- � �� Townshlp Name Township No. Range No Section No. Fiact�on�sm.-s Ig) Date Sealed Date Well or Bonng Constructed 8rt��a II7 23 b8 i�-Q£��2�. 4 ��. Numencal Street Address or Fire Number and Cny of Well or Bonng Locat�on y � t 332# N S�Qre lJ�* Vtd�d Depih Before Sealmg �i _ft Orig�nal Depth �� tt Show exact loca6on of well or boring Sketch� of well or bonng ADUIFER(S) STATIC WATER LEVEL m section grid wrth"X". bcation, s1�o�A�g property Single Aquder � Mult�aquder lines,roads a dbwldings. N �� . WELUBORING �Measured ❑ Esnmated � � � � �� R�� f/�Water Supply Well [�1oni1.Well —�- -i— —i-- --;-- �r� f + 4 ❑ Em.Bore Hole ❑Olher �._tt. �ielow ❑ above land suriace � � � � " —�- -i-- -i-- --;-- � �' CASING TYPE(S) � � � W � � I �,i i i � G� -;-- -�-- --i-- --i-- Steel Plastic �Tile �Other - }�mile -�-- -�-- -�-- —�— � CASING(S) Diameter Depth Set m oversize hole? Annular space initially grouted? S +� � /� � � �r miie� _{'.`_�in.trom v �o� ft. ❑ �es No ❑ �es ❑ No ❑ Unknown PROPERTY OWNER'S NAME in.from to M. ❑ Yes ❑No ❑ Ves ❑No ❑ Unknown w. Property owner's iling addres f diN rent Ihan wetl locanon address indiwted above. in.irom to ft..�z�` ❑ Yes ❑No ❑ �e5 ❑No ❑ Unknown atttt:�ssp �r��g8 tq�� BAy�� 4 �t � SCREEWOPENNOLE `, .� .. ��a �aa� s s ��,��t(�jj,�� +�� „�j Screeni�om to R,��:�f7penHolefrom�to� ft. OBSTRUCTIONS WELL OWNER'S NAME � ❑ Rods/Drop Pipe ❑ Check Valve(s)� �❑ Debris�n Fill �No Obsiruction Well owners mailing address it diflerent than property owner's address indiwted above. Type of Obstructions(D85Cribe) Obstructions removed? ❑ Yes ❑ No Describe PUMP TYPe GEOLOOICAL MATERIAL COLOR HARDNESS OF FROM 70 � Removed �Not Present ❑ Other FORMATION N not krawn,indicate estimeted tormatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE MOLE: � � � � �Jo Annular Space Exists ❑Annular space grouted with tremie pipe ❑Casing Perfo�ation/Removal in.from to ft. ❑ Pertorated ❑ Removed in.trom �o ft. ❑ PeAorated ❑ Removed Type of peAorator ❑ Other GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 Ibs.) Grouting Matenal _��,� � from �— ro.� ft. yards � bags from to R. yards bags from to fl. yards begs from to__ tt. yards bags REMARKS,SOURCE OF DATA,DIFflCULT1ES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation contained in Mis report is true to the best of my knowledge. �1c�r� St+��la 6#eI.2Ucfliin �. I�c. Contracror Business me ` License a Regishation I'�io. , ; �' �� .z� �,..i uthonzed epresentative Sigdature � Date r v'ti•`... . �v �!�aC2.t1"��.. ;-.��A�,r.�p�, u � �+�/1� � Name ol Person Sealing.�� ell or Bonng fl �h