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� • MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring � <br /> WELL OF 80RING LOCATION yyELL AND BORING SEALING RECORD Sealing No. �H �,'�QO1,� <br /> County Name � <br /> Minnesota Unique Well No. <br /> /� Minnesota Statutes.Chapte�1031 or W-series No. <br /> ��li���� (�eeve Hank M nW krqwn) �_--__... � <br /> Township Name j Township No.Range No Sectlon No. Fraction(sm.-i Ig� Date Sealed Date Well or Boring Constructed <br /> i <br /> tft�or�� I1 fi 23 Oa �4-aQ0 �.7 ` <br /> Numerical Sireet Adtl�ess or Fire Number and Ciry of Well or Bonng Locahon <br />.�. 3y{, g �rp /�t � , h <br /> V9� t� ai'b(3s"E �_'j �t�QQ �j��l Depth Before Sealing��S„/ M. Original Depih v <br /> Show exact bcation of N•ell or bonng Sketch map of weli or bonng AOUIFER(S) STATIC WATER LEVEL <br /> insection grid with"X". location, sh g propeny Single Aywfer � MultiaquRer <br /> - I es,road buildings <br /> N AI_ , '����� WELUBORING � �Measured ❑ Estimated <br /> .�ly.�.�� <br /> �Water Supply Well ❑Monit Well � <br /> ❑ Env.Bore Hole ❑Other _ � R. �I below ❑ above land surface <br /> W -- - -i-- -i-- --i-- E � CASING TVPE(S) <br /> ' I I � <br /> � � � � �G <br /> -�-- -�- --i-- --�-- � ❑Steel ❑ Plas6c ❑Tile � Other c � (��_�� <br /> I I � Ylmile <br /> —�- -i— -.�-- --�— � CASING(S) <br /> \ Diameter Depth Set in oversize hole? Annular space initially grouted7 <br /> S �M ♦/ �,�/ <br /> �i mae� � � in.irom� to�v ft. ❑ �es �No ❑ �es ❑No ❑ Unknown <br /> PROPERTV OWNER'S NAME in.from to k. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> Prope wners a n res � itterent th ti ess a bove. in.from to k. ❑ Yes ❑No ❑ 1'es ❑No ❑ Unknown <br /> 2Z45 French Lake A� SCREEWOPEN HOLE <br /> ��p�S t 8� i4i� S 5 J 7� Screen from to ft. Open Hole from �to k. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owners meiling adOress if diHarent then property owner's adtlress indicated above. TypB oi ObSlfuCtiOnS(DeSClibB)1(/�l�� �1�L � �y� ��`"G�/����� <br /> Obstruclions removed? �,'Yes ❑ No Describe <br /> PUMP <br /> Type <br /> 6EOLOOICA�MATERIAL COLOR HARDNESS OF FROM TO � Removed Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OF CASING AND BORE HOLE: <br /> �il'tJo Annular Space Exists <br /> I"` <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to tt. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material pn-�T`�//�"�Trom �_ to� Ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to__ ft. 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 weli or bo�ing wav sealacl in acrordance with Minneso!a Rules,Chapte�"-725. '?�e In'orma?Io�conta�n�in Lhis re�rt is <br /> true to ihe bes!o`my knowledge. <br /> Don Stodols �tell Ur3liing C+�. I�+c 271T2 <br /> , ----_ -- - — <br /> � Conhactur Busrn�ss Nam- Lrcense or RegistreNon l�io. <br /> ' '/�'- �:.� :J�:J <br /> thori R enta ive Signature Dete <br /> \ <br /> `,y �w, <br /> l ,J�-"�-v�.�✓`/ :_��(Y"�.r "—_-- <br /> ,.__ , � <br /> LOCAL COR`Y ��Q��� � Name o�Person SZ lin�Well or Bodng <br /> H ..�� <br />