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> <br /> WELL OR BORING LOCATION <br /> Count'Name 7--- <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well erx)Boring rH <br /> WELL AND BORING SEALING RECORD Sealing No. — <br /> Minnesota <br /> Unique <br /> Well <br /> Hennepin ... Minnesota Statutes,Chapter 1031 or W-series No. <br /> s.m era II not known) <br /> Township Name Township No. Range No. Section No. Fraction-(sur.i Ig.) Date Sealed Date Well or Boring Constructed <br /> Orme 117 13 02 22-4002. to NII) <br /> Numerical Street Address or Fire Number and City of Well or Boring Location g�yf� r <br /> 15 0bard M � S pth Before Sealing Age) ft. /Original Depth 7 ft <br /> Show exact location of well or boring Sketch map of well or lx npg IFER(S) STATIC WATER LEVEL <br /> in section grid with le. location, showing proptell' Sin le Aquifer <br /> lines,roads,and buildin g q ❑ Multiaquiter <br /> N WELLIBORING %Measured 0 Estimated <br /> ' ) - 4aJ' <br /> /Water Supply Well ❑Monis.Well f <br /> --T --T---l-- -1-_- <br /> Env.Bore Hole 0 Other _ Itfig k Oielow . 0 above land surface <br /> --+---4----+----1--- ... <br /> yy . . E i„54i CASING TYPES) <br /> Ff1 -I-"-'T teel ❑Plastic ❑Tile ❑Other <br /> I Smile i�r'' <br /> --+---+---4.----1--- 1 CASING(S) <br /> Diameter Depth Set in oversize hole? <br /> S <br /> Ili-- J' 'f ,y't (Ir Annular space initially grouted? <br /> r roe { in.from /J to h, <br /> 0 Yes No 0 Yes 0 No 0 Unknown <br /> PROPERTY OWNER'S NAME I in.from to ft. ❑Yes ❑No 0 Yes 0 No 0 Unknown <br /> Property:owner's mailing address if different the I location address indicated above. in.from to ft. 0 Yes 0 No ❑Yes 0 No ❑Unknown <br /> 20305 Lalartiev &v B SCREEN/OPEN HOLE <br /> set lir Mir 53331 . Screen from ICA.E r to _ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME .... 0 Rods/Drop Pipe 0 Check Valve(s) ❑Debris 0 Fill No Obstruction <br /> Welowner's mailing address if different than properly owner's address indicated above. Type of Obstructions(Describe) - <br /> Obstructions removed? 0 Yes 0 No . Describe <br /> PUMP <br /> Type <br /> HARDNESS OF 0 Removed )(Not Present 0 Other <br /> OIEOLO0IK AL MATERIAL COLOR FROM TO <br /> FORMATION METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND'BORE'HOLE: <br /> a not known.Indicate estimeted"fomudiori log from nearby wellor boring. <br /> } to Annular Space Exists <br /> d1 © r 0 Annular space grouted with uremia pipe <br /> 0 Casing Perforation//Removal <br /> in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> Type of perforator <br /> 0 Other <br /> • • GROUTING MATERIAL(S) (One bbaa�g;�offc�cement..94 lbs.,one bag of bentonite.60 lbs.)-. <br /> Grouting Material,4ii ! //1T".R�from rG { to ISO 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,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> • Other unsealed and unused well or boring on property? 0 Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed M accordance with Minnesota Rules,Chapter 4725. The information contained in this report Ii <br /> true to the best of my knowledge. <br /> DOS Stella* Well Drilling CO** Ins 21172 <br /> Contractor Business Name License or Registration No. <br /> ..S— 0 CO <br /> VirreRepr sentathro Sig ramie Date <br /> LOCAL COPY H 1 S ■ 5 S O Name of Person or Bourg <br />