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MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring � ��+.q +��rt � <br /> WELL OR BORING LOCATION Sealmg No. I�"� ,��� g C <br /> Counry Name WELL AND BORING SEALING RECORD M,��eso,a��,q�e No — <br /> ��p Minnesota Sfatutes,Chapter 1031 or W-series No. � <br /> \. N~ ILeave blank if nol known) -- <br /> Township Name Township No. Range No. Section No. FracGon(sm.->Ig.) Date Sealed Date Welt or Bonng ConsVuctetl <br /> a� <br /> C.�✓'_ h�.> r r. <br /> !? �" f�" �"� � -�/ ���".' <br /> Numencal SVeet Atldress or Fire Number and Gry of Well or Bonng Locahon � <br /> � 7 � � Z <br /> 1�_', /�L,� ._ � �,.����� ��u� �L J Depth Before Sealing � ���- M. Original Depth M <br /> d <br /> Show exact loca6on of w•ell or bonng Sketch map of well or bonng AOUIFER(S) STATIC WATER LEVEL <br /> in section grid wrth"X'. location, showing property �Single Aywfer ❑ Multiaquiter <br /> - lines,roads,and bwldings. <br /> N ,,,� WELUBORING �Measured ❑ Esumated <br /> � � N�' �waier Suppiy Weu ❑Monit Well <br /> -�-- - - -;-- - � �,/ <br /> ; ; ; --} , ❑ Ern.Bore Hole ❑Other _ 0./"� R. L•y below ❑ above land surface <br /> � �y�� <br /> w --�- - — -i-- --i-- E ,� � V''� CASING TVPE�S) . <br /> y � � � � � <br /> r � � � � <br /> ; —�- -�- -;-- --�-- � ,_ �Steel ❑ Plastic ❑Tile ❑Other <br /> � u mde � � <br /> � � � � ,, CASING <br /> —�- -�-- -�— --�- <br /> � --S � Diameter Depth Set in oversize hole? Annualar space iNtially grouted? <br /> S �,� .._-..-_. � ` � <br /> ��m�� in.irom � to °�� �� R. ❑ Yes �No ❑ Yes ❑No � Unknown <br /> � PROPERTY OWNER'S NAME � in.from to fl. ❑ �es ❑No ❑ �es ❑No ❑ Unknown <br /> I�J: 1 i} I � - � <br /> Properry owner's mailirg address If diRerent than well IocaUon address mdicated above. in.trom to ft. ❑ Yes ❑ No ❑�Yes ❑No ❑ Unknown <br /> =; ir-�,y"L. SCREEWOPEN MOLE <br /> Screen from to k. Open Hole from to k. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill � No Obstruction <br /> Well owner's mailing eddress if different than propeTj owner's address mdicated above. Type ot Obstructions(Describe) �" �-�� <br /> Obstruclions removed? �Yes ❑ No Describe �" L''�� <br /> PUMP <br /> Type <br /> GEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed Q� Not Present ❑ Other <br /> FORMATION <br /> If not known,irWicete estimated formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � No Annular Space Exists <br /> iv/ry ❑Annular space grouted with tremie pipe <br /> � ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> Type of pertorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> 1 � <br /> �' ,. S / <br /> Grouting Matenal � ' � 1'� �' i E from � to �+� ft. yards / begs <br /> trom to tt. yards bags <br /> from to ft. yards bags <br /> from to-- R. yards bags <br /> REYARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Olher unsealed and unused well or boring on property? ❑Yes �No How many? <br /> ��� �,. � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> \;.... � , b.= <br /> � This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information conteined in this report is <br /> - true ro the best of my knowledge. <br /> E,�j;.. �,:, . �`,1,a 1 � ,7; `� `7 <br /> Confrador Business Name License a RegishaGon l'vo. <br /> ' I �.,,�,-._ ( - J j ` S`I <br /> `� <br /> Authonzed Representefive SigneNre Dare <br /> ..'1 � � �,JR � �. - 1 55 <br /> 1' <br /> H � Name ol Person Seeling Well oi Bonng <br /> L�i/V. '�� <br /> HE-01434-04 8�98 R <br />