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MAR-22-2011 11 : 12 AM LEUTHNER WELL INC 952 443 2582 P. 02
<br /> • Minnesota Well end Boring : • , .ilIl
<br /> MINNESOTA DEPARTMENT OF HEALTH Sealing No.
<br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD MIW ve nmea No ue Well No,
<br /> Cou•y'ems 4. Minnesota Statutes,Chaplet 1091 F.urrcw+rh
<br /> i/ // Dew Well or Boring Construct �.
<br /> �.. ., Det•seel.d,.► /G 0 -
<br /> rnshlp Name r nrhip'o Range No. Bectl_on No, F .b on(fir 3ig.) 'I /
<br /> ' 4 JI. Original Depth
<br /> Latitude —_.__ degrees___ minulee—— seconds Depth before Beeung—
<br /> LPB minut.e-- seconds STATIC WATER LEVEL
<br /> LOCATION: Longltud..___._ depn•e AOUI�ER(9) ,
<br /> 01 Single Aquifer ❑Munlequller r` Estimated Dab Measurod.�
<br /> Meaeuroe ❑ •
<br /> Numerical Street Address or Fire Number and Cl ..1 II or c ring Lobe m yyeLLJOGRING •
<br /> J - I :d Water-Supply Well ❑Monk.Well above land surface"� Other -n, ❑below L� _
<br /> Sketch map of Well or boring ❑Env gore Hole ❑
<br /> i n exact to anon•/ Ir •drinq location,snowing prop
<br /> in section grid with" r I ee,roads,and b CASING TYPE(e)
<br /> N
<br /> 1..,.._t__. 9 .r.Steel ❑Plastic C]Tile ❑Otner----
<br /> 1 ) • WELLHEAD COMPLETION
<br /> i_"'_i__.••i , ❑AI Oreae Indd.: ❑Baaement Offset
<br /> W E Outelds: []Well House
<br /> I
<br /> •
<br /> ❑Burted Ca Well Plt
<br /> I ! ;--' TIM* Asides Adapter/unit ❑Burled!
<br /> --.4.----1----Ir---14--- I41( ❑WII Pk ❑Other
<br /> e 1 ❑Other_
<br /> Nrilli ..
<br /> R'S NAM. • •- NV NAME CASIDiem (o) Ini aiL4'�
<br /> I:
<br /> PRO:•!�- p. Set In oversize hole? Ahnuler apace •'r n',I'1
<br /> ,J � _ ✓� r. DlemylSr L
<br /> Pro :.I'ti•ddrae.' d'�. '�en •.I I a,en eddnu lndlo•ud ebov •
<br /> td II. ❑VN ❑No [:Yes ❑No ❑ ..;.,•.•,. ,
<br /> 641)P411411'
<br /> �� n. ❑Yee ❑No ❑Yea ❑No ❑LMi :';
<br /> In,Irom�— to �• • 1I'i
<br /> J�� _. in,from______
<br /> ft. ❑Yee ❑No ❑Yea ❑tee Q UNgiown
<br /> ili
<br /> SCREEN/OPEN HOLE , ,I;!.,•;:•;I
<br /> WELLOWNER'9 NAME/COMPANY NAME !i' •;•'"•IiI li
<br /> e�'� to _.3n. Open Hole from to l:•lug,l • '
<br /> Screen Irom u''
<br /> Well owner's mailing address II 4ki•nrrt than property 4"rn•r's edema IndlceleC above ((/(�wv.,��l[ - •• •'I :11;14;11I
<br /> OOSTWUCTIONS •' ` ..:i1;.:,•!,!1:;
<br /> , '
<br /> ❑Rods/Orop Roo ❑Cheok Valve(s) [2Debrle ❑Fill ❑No Obstruction I;,i,.
<br /> Type of Obstructions(Deecrlbe) q,l;,;iii;,i
<br /> GEOLOGICAL MATCRI4COLOR rt1RDNlA90R FROM TO Obstructions removed? ❑Yee ❑No Describe_ I
<br /> li
<br /> i I'li,.;i
<br /> FOANATION PUMP •
<br /> If not known,Indiceh estimated formation l0•from nearby well or boring. ;'• I;i :li;i
<br /> TyDe_ � ':ih , 'it rl'�:,:I
<br /> 7 Removed ❑Not Present ❑Other , •
<br /> ' `, McTMOD USED TO SIAL ANNULAR SPACE IITWEbN a CASINOS,OR CASINO AND Wit HOLE: II luuil.II^ill'
<br /> ❑Na Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Gaeing PeROral I;i•liit.
<br /> • ❑Perforated ❑
<br /> •
<br /> In,from to II. .'Il • :,,!:;ai:
<br /> • in.from to n. ❑Perforated : ❑Removed
<br /> •
<br /> 1" Type of Perforator • . • "I Ih'
<br /> • j,;j;lli l
<br /> ,I
<br /> GROUTING MATERIAL(9) (On.big of cement•55 lbs..one beg of bentonite•50 lbw.) l,
<br /> ,,;1,11;1 ill I ith
<br /> I,
<br /> Grouting Material L viol ,;l•;•i Illi
<br /> T I:•..
<br /> ri MI!'
<br /> from to n. yards b!p!„
<br /> from to ft
<br /> ...Li• .I,, •.li u
<br /> OTHER waLLli AND BORINGS • :('I'::' II 1':
<br /> REMARMSOURCE OF DATA,DIF�ICULTICS IN SEALING Other unsealed and unused well or boring on property? ❑`lea No How many? I''i.wi i I!;
<br /> I LICENSED OR REGISTERED CONTRACTOR CEIrTIPICATION • I' ,0 u:R'i
<br /> Thla well or boring wee sealed In accordance with Minnesota Flutes,Chapter 4725 The IMdrmatlon c ndai lad Ii1.1S+1i;46el
<br /> Is Inks to tn..•et of my kn•, Op. ;. •ill I'
<br /> r.: , .1.,.. _ i
<br /> L -: ..sires.Nems Lk•as of' trefloA I O.
<br /> ! /l �, ` ie fl
<br /> ff✓��_i ; i�- _/'� ., lii',.. i,.
<br /> LOCAL COPY H 284447 :r -� .,or_o,,�.
<br /> 'l 1 WIis.
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