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WELLOR 80RING LOCAnON MINNESOTA DEPARTMENT OF HFALTH M�nnesota Well and Bor�ng ; 14 40 7 8 �
WELL AND BORING SEALING RECORD Sealing No H
�'�1��'"e Minnesota Urnque No. — — " ,
}}e����yl jZ Mrnnesota Statutes,Chapter 1031 or W-series No. �
(Leave b�ank A no�known) —J
Tovmslep Narne � Townsliip No. Range No. Section No- fracnon�sm.-s Ig.) Date Sealed Date Well or Boring Constructetl
Oronc� 1 i 7 2 s 17 � " % ���'
N�rnerlcal Streel Address a Fire Number and Ciry ot Weli or Bodng�ocafion � r .
i
L L L J �tli�(��7WC+OC� Rf�. �c'� Z�tte� Mj-t. �P!;'� r Seabng -.%�-� tt Origlnal Depth ��� n �
Stww exact br.aDon d vreb or bonng Skelch map of well o bonng AOUIFER(S) STATIC WATER LEVEL
n section gd wM'X'. locatlon, showing erty S�ngle Ayuder � Multiaquifer
Ifnes,roads,and bwl �
N '� WELUBORING �Measured ❑ ESGmated
� l� �� Water Suppry Well ❑Monit.Well �
- - - - - - -i-- j
T T � yv � � ❑ Env.Bore Hole ❑Other _ �� f R. �pelow ❑ above Wnd surtace
� '�_. `
W -T- -T- -T- -�-- E . CASING TYPE�S)
-T- --�- -i-- -i-- � ---.—�.. � ,', �Steel ❑ Plastic ❑Tile ❑Othe�
\�.
u mYe
-1- -+- -�-- -�-- � I-__ � .�.� CASING
� Diameter Depth � Set in oversize hole? Annualar space initially grouted?
� g � ` � !� —,
�„�� ( � -t �_ m.from� to�� ft. ❑ Yes �No ❑ �es ❑No ❑Unknown
PFiOPERTY OVIMER'S NAME in.irom to fl. ❑ Yes ❑No ❑ Yes �No ❑ Unknown
Todd Pie �er
Ropery awners mai�g address if dAlerent than well locatwn a0d.ess indicated above. in.from to ft. ❑ Ves ❑No ❑ Yes Q No ❑ Unknown
L} / � —C��7[t SCREEWOPEN HOLE
I
Screen irom ��� ro ��� tt. Open Hole from to f1.
OBSTRUCTIONS
���aS� �Rods/Dro Pi e ❑Check Valve s ❑ Debris
p p ( ) ❑Fill ❑ No Obstructbn
WM oiwrrs m�ig ad�sss if diRerent Man property owners adAress indicated above. Type o(Obstructions(Describe)-^�f�'���j� �—��� g �JU�Y�/� ��
Obstructionsremoved? �Yes ❑No Describe
PUMP £
Type
,�L+ ( :,i(�p`\f".
I;EOLOC�CAL YATEIYAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other
FOflMAT10N
N no[Ivnw�,indeals sYmebd forms6on log from nearbY well or bonng. METHOO USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OH CASING AND BORE HOLE:
f� � 'I,� ,y+9 No Annular Space Exits
` 3- ❑ Annular space grouted with tremie pipe
%i ❑ Casing PeAoratioNRemoval
i .
in.from to ..R:`Jf ❑ PeAorated ❑ Remwed
in.from to ft. ❑ PeAo�a�d ❑ Rertbved
Type of perforator
❑ ott�er
GROUTING MATERIAL(S)
,
Grouting Material ���'`� r'''�`��`�^tjlrom �-J ro��� �) tt. yards � bags
from to It. yards bays
from to h. yerds begs
from to_— k. yaNs begs
RBIARKS,SOURCE OF DATA,DIFFICULTIES IN SEAUNG OTHER W ELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Ves o How man�/l
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordence with Minnesota Rules,Chapter 4725. The irAwrt�ion caMsined in Cas repoR ia
_. true to the best of my knowledge.
..,.. .. � � .
�GiV ;�T(3C}C3LA WELL DRZLL7t3[i c�y -���; �� � �F
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�"; Contreaor Business Name , -'� L.icense a lvo.
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, ., / - / F '
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• ' m resenrarive slynarure � ows
- ..-���"��'`'',Jl„►�1�Y`'.,.,,•
14 4`�7 8 Name ol Person Sbeling Well or Bonng ._
LOCALCOPY H 4
FiE-01434-03 2/97 R