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Pt P R-17-99 04 : 19 Am P. 01
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<br /> .- MINNESOTA DEPARTMENT Or HEALTI I M)nnosota Well anti D01.1110 .
<br /> WELL OOING LOCATION WELL AND BORING SEALING RECORD .14 . 1 .4. 3--1_
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<br /> M,ntlefota StAlult:6 Chaptvi 1031 of W•ser,ff,NQ 1
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<br /> T.,retip Name ,...oship No ,,,,,,i,-...No Secl,on No. rpre;liern(WI. 1.ig) Mite beak:, , ,. nat.Waill or Boring c:96,.,.Ifutted
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<br /> I I ..) --71' _,._).''. I / 1 ' 47. ' •- ., i ...
<br /> itiffiettilil Slifoet,A,joyieto.e,lirr,Nurikel on Utty+.1,1,-,NII of:bd....1:11 ne::10,-0 1.-- - -•
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<br /> , !..,12....• .L_ Cepth Bute,,e:4rtnillig h. 0,,o,....1 D,,,It, _ .._... .__ ti
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<br /> Shot eypct fataloe Ol well cy bohno SLelir..h mew 01,ornii e,(,,, ,e3 AQUIFER(S) STATIC WATEP LEVEL
<br /> le section grel with'X• , . ,nu....,,,,o prnixifiv af-:ongle A ,,e,i I I
<br /> liner.,ru,Kt-, And tiudO"-Sr•
<br /> N WELUBOPiNG ,1 1.,Ao:rorred n ce;,..r.a,„0
<br /> / L2 Wm.,,suDDIV Well 0 M ' Wr"
<br /> • - • • • f j Ef,v• Ekere HOLE. U Othe.r. .... _. ._./;;;;‘. 2___ft pe)I.Kan,v 0 rthovo Iniel reirtelCe
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<br /> • CASING TYPE(S)
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<br /> . . , . CASINO
<br /> 01[0)0, Dope, Set lo Ovar./E.POO Afloualar sow.*xxoally it
<br /> S .H.I : I <- , ,
<br /> 11.---...r rrtirg •--41 "‹.
<br /> 4--__._,1 .....1,:,... xl horn .„..._ to .._,L.,I„ * n. r j`ie, Do nye, DNI.' Ohl.
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<br /> PROPERTT, V.'NAME - - - . ..i, ZI 4 tri Iron,__. it, .. ft fl Yr'. 0 Nu 0 Ye:. fl No LI Unknown
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<br /> I Mailrng 000,i,,r,,1 dotterel,'04,-,woe i,,e4,0,,,,,eddros,... .,Itwl above in.hum— to__ - it• U Yes 0 No fl yeti n Ise., 0 unk,.......
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<br /> 1 7 ' SCREEN/OPEN HOLE
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<br /> ii i:..e.. .1./?1
<br /> -— ,,..„„„n, . .; (:,'...... b,--i. ..,._ ti Open l'Idle fr(rrn-..... — to-• — " ..
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<br /> OBSTRIXTION5
<br /> WELL OWNER'S NALIC U Root/Drop Pipe ELI Chock valva/s1 0 Det,ele„. 0 Fill 0 No 00eiroction
<br /> 'Well cropeWt eiAeleig it tiaras Sher vi;O,..,ry ownix••.:ed,Pxf.i.o101eatol.4,,,,,, Typn of ejt-,.:Iruelions(rint;oribe) -.__.• —... ... •
<br /> 01,0tiVMInns tOrTIOVOr.11 al Yes n NO CIWiCSIbe —...•- • ..
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<br /> PUMP
<br /> Type_.. ____.......
<br /> GEOLOGICAL MATERIAL COLOR HARDNESs of f nom To c.3 Ruoitwee LI Nei Pro.r.ont n (Mho r ' .......-
<br /> F04,MATION I . .. ............ ,.... ..
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<br /> TtIOD USED TO SF AL ANNULAR SPACE a ETWEEN 2 CASINGS,OR CASING AND BORE HOLE;
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<br /> I not encen,indrane eahn.atea forrnatkle lett I,..r,nearby well ne bonne
<br /> •." n Nu Annum,Space Exlis
<br /> . 0 Annular space grouted with tromIo p,Pe •
<br /> 0 Ce.$•ing PerloiaIon/Removal
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<br /> In.Irom tO... ... ft (-3 Performed U Rernovee
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<br /> In from_.... _ to 41 0 Perforated 0 Bud
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<br /> I• - • .— Type of perlorater ,..
<br /> —.-...-- _ _..... n Other _
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<br /> ., apicariNGOAATeRIAl(s) -
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<br /> Grouting Materiel • ,...„,-.:01...,.,../ _ TAME ..7,4_. IMP
<br /> trQm ,. 10 R. yards bhp
<br /> ,- 1 1from to ft. Yoffie ••___ Mtge
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<br /> .,_... - ffOre, to _. . -. --- mit; bies
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<br /> IIMMARCS,SOURCE Of DATA,DIFFICULTIES IN SEALING.........-----.------,-----.....OTHER WELLS AND BORINGS
<br /> Other unsealed and unused well or E.OrItlg on properly? 0 Yes Er No ttow many?__ ___...,
<br /> • LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
<br /> IN.;well tic bOrIN War:sealed in accordance with Minnesota Ruln%,Chartter4/25 The information urea/nod et II*report Ie
<br /> true to MO best uf my ImONY go.
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<br /> '. reAor fa .,.: -.-"i4004244 144ififjber' Ail
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<br /> AP . lAiltgi .tUf a I ' t''''le'--4-/''.(74.4.s1- -.• .'
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<br /> orralara , .,,4 , . • • ., _... ... -
<br /> i ) . LocAi. oy H 144431 Name al f`41443Zang WWII Lie.k.UFAP .. .' ..
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<br /> 511-01431-03 var ft
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