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'-� � � � WEIL OR BORING IOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ��{ � —� WELL AND BORING SEALING RECORD sea��9 No. i H 1 Counry Name Minnesota Unique Well No. r -- Minnesota Statutes,Chapter 1031 or W-series No. I — � 11.aM dank tl rwl known) L_ Township Name Townsh�p No. Range No. Section No. Fraction�sm i Ig) Date Sealed Date Well or Boring Const�ucted � �1 V� � �n`�1J �� Numencal Street Address or Fire Number and Gry ot Well or Boring Locahon � � � � � Depth Before Sealing � R Onginal Depth h Show exact locahon ot veell or boring Sketch ma d wely,or bonng A IFER(S) STATIC WATER LEVEL in section grid with"X". locahon,��`� property Single Aywfer ❑ MWtiaquifer lines,roads. n11 uildings. N � WELUBORING ` �leasured ❑ Estimated � � � � f;d� ❑Water Supply Wellz�MoniL Well � - - - -- -- -- -- -- • i "'� {�� ";�o ❑ Env.Bore Hole ❑Other _ _�ft. �elow ❑ above land surtace i � i k W --�- -�-- -i-- —�— E e �� CASING TYPE(S) � � � � ^ � � ;:� � � � —�- -�-- -i— --i-- � �� ❑Steel �Plastic �Tile � Other ylmile � —`- -�-- -�-- --�— � CASING(S) Diameter Depth , Set in oversrze hole? Mnular space initially grouted7 II(�—t miie� �Jin.from� to�� R ❑ Yes �tNo 0 �es ❑No ❑ Unknown /� PROPERTV OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown Property owner's maihng address a diHerent than well Iceation adtlress indicated above. in.from to fl. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown , $�.,�,�: e^�a�,.� $�,.t Qg� SCREEWOPENHOLE � 1pGi ��Q �� Screen from�to� fl. Open Hole from ro R. �.i�TZ�L�n��f �ii� �l��S � �� OBSTRUCTIONS WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill �No Obstruction Well owners mailing address it ditterern Man property ownar's atltlress indicated above. Type of Obslruc�ionS(D9SC�ibe) � Obstructions removed? ❑ Yes ❑ No Describe PUMP Type GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ❑ Not Present Other FORMATION � It not known,indicale estimated formatbn log from nearby well or bonng. METMOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: . , t77vo Annular Space Exists �"'J• ` ❑Annular space grouted with tremie pipe ❑Casing PeAoration/Removal in.from to ft. ❑ Perfora[ed ❑ Removed in.from to R ❑ PeAorated ❑ Removed Type of peAorator ❑ Other GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 Ibs.) 9 �-�-�i�7*sr^�� Y � 9 Groutin Material +� to R. ards ba s irom to fl. yards bags . � from to fl. yards bags from to__ ft. yards bags REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes o How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accrordance wiM Minnesota Rules,Chapter 4725. The infortnation contained in Mis report is true to the best ot my knowledge. �t�� SEt�de2a �eI1 �zi313ng �a., I�c. 27172 Confractor Business Name License a Registretion Cvo. �..-- '� �----"�' r— j �r' �,j — ,,�/-G C�J on R p sentative Signature " Date '`.`, .. �„ti✓^"1- .�:`>�Y"-'�.�-�'f�� �/v:•: , L��.,�py� H � �� p Name o/Person Sealing W I or Boring x