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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and eoring ��5 3 2 5 I
WELL OR BORING LOCATION Sealing No. H i
����N�,B WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes,Chapter 1031 or�W�p e�s N�o.
�
Township Name Townshlp No. Range No.Sectlon No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
OrQ�O k k k � /� /
V
GPS ��de degrees_ minutes_ seconds Depth Before Sealin �� 8. Original Depth R �
LQCATION: Longitude_ degrees minutes_ seconds ��R�S) STATIC WATER LEVEL
Numarical Street Address or Flre Number and City of WeII or�ring Locatlon ingle Aqu'rfer ❑MulUaquffer �+
WEJ'L/BORING Measured ❑Estlmated Date Measured✓ `�
12�5 ArTmr St (�no 55391 ;�Water-Suppiy Well ❑Monft.Well /�./� � ,y
Show enact locadon of well or boring Sketch map of well or ring ��gore Hole ❑Other _�fL l�below ❑above land surface
in section grid with°X." loca8on,showing pro • �
N Iines,roa\`d buitdi CASINO TYPE(S)
--'-----'-----`-----`-- �/
���- s��i ❑Pi�uo ❑r�ia ❑ou,e�
; ; ; ;
--i------'r-----l-----�-- WELLHEAD COMPLETION
W__�_____Y_____�,_____�__ E T u[side ell House At Grade I�Id ment Ottset
O : ❑W ❑ e:�
'h Mne �� ❑pitiess qdapterNnk ❑Buried ❑Well Ptt
--:-----T----�-----:- 1
- ❑s�hau ;
' ' S ' ' `�Well PR �
❑other
�1 Mile� ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASINO(S) �
Ci t?� 4L'C�ilO o��eca�� � Depth � Set in oversize hale7 Mnuler space fnitlally grouted? �
Property owneYs malAng addreas M dlHererrt then well ta�tlon addreas indicated above �_in.from � to�R ❑Yes �No ❑Yes ❑NO ❑UnlmoWn
P�O� ��q � in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unlmown I
C�T.Stix.! B�' �?�T 5����
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unlmown I
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE ,
I
Well ownePs malling address H ditferent than properry ownets address IrMicat�above ��n ftom�to r s� ft. Open Hote from to ft.
OBSTHUCTIONS i
�tods/Drop Pipe ❑Check Valve(s) ❑Debris ❑FII ❑No Obstruction
Type of ObsVuctions(Describe) NAw� /�.�{"T �' ����LI—� l
GEOLOGICAL MATERIAL COLOR �DNEss oR �OM � Obstructions removed7 Yes ❑No Describe
FORnoanoN
If not known,indirate estimated tormadon log from nearby well or boring. P�MP �
. � T,� �7'IR01� �ut1n&�
� �Flemoved ❑Not Present ❑Other
ME�HOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: i
No Mnular Space Exists ❑Mnular Space Grouted with Tremle Pipe ❑Casing PertoratloNRemoval
in.from to ft. ❑PerForated ❑Removed '
in.from to ft. ❑Perforated ❑Removed
I
Type of Perforetor !
❑other
aROUTING MATERIAL(S) (Orre bag of cemeM=94 Ibs.,orre bag of berrtonile=501bs.)
w �.�,,� f '�j!�
Grouting Material/vL�/ C:G...��lfrom � to}�(t. yards�bags II
from to ft. yards bags ',
from to ft. yards bags ''
OTHER WELLS AND BORINGS i
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or bodng on property7 ❑Yes o How many7 I
LICENSED OH REGISTERED CONTHACTOR CERTIFlCATION �
� This well or boring was sealed in axordance w(th Minnesota Rules,Chapter 4725.The informaUon contained in this report
is true to the best of my Imowladge.
l�0il Sfi0a.0�8 �1.Z j?l�. CO. IIIC.
Licensee Busfness N License or Regishadon No.
/�'i-a-G7
� Ce e epreserrtaWe Sign Certifled Rep.No. Date
�ANT-FILE WITH PROPERTY ��5 3 2 5 Name of Person Sealirtg Well or Bodng I
•WELL OWNER COPY H
IC#140-0423 5l07R