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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 3 6 3 8 <br /> WELL OR BORING LOCATION Sealing No. <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Minnesota Statutes,Chapter f031 or W-series No. <br /> (Leave blank if not known) <br /> Township e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed 1 Date Well or Boring Constructed <br /> _, ;_t t�GE. <br /> n <br /> �ZQ� <br /> Numerica Street Address or Fire Number and City of Well or Boring Location <br /> / � <br /> Depth Before Sealing �� ft. Original Depth J0� ft. <br /> Show exact location of well or boring Sketch r�p of �I�wr boring A�UIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, s g properry Single Aquifer ❑ Multiaquifer <br /> -�— nd buildings. <br /> N WELUBORING ❑ Measured �Estimated <br /> � � � � - �iVater Supply Well ❑Monit.Well � <br /> 'Y' 'Y' -'l-' '-1-- <br /> � ❑ Env.Bore Hole ❑Other �ft. �elow ❑above land surface <br /> � � � � T ' <br /> W --�- -;-- -i-- --;-- E � CASING TVPE(S) <br /> ��- <br /> � � � i -:�,., <br /> --�- -�-- -i-- --�-- � Steel ❑ Plastic ❑Tile ❑Other <br /> '/.mile <br /> --�- -�-- -�-- --�-- � CASING <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> L� i <br /> y(�1 mile� ��n.from� to�� ft. ❑ Yes �No ❑ Yes ❑No ❑ Unknown <br /> I <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> Property owner's mailing address if different than well location address indic�ate}d above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknoti:�n <br /> �J-R-j-o�y _ C_� r t'�e�-1 SCREEN/OPEN HOLE <br /> r � <br /> Screen from�to�� ft. Open Hole from to ft. <br /> OBSTR UCTI O N/D E B RIS/FI LL <br /> WELL OWNER'S NAME �bstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill �(�D /C[J�/ 1 tL /��P1//'��.J <br /> Obstruction/Debris/Fill removed? �Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATER�AL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log rrom nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exits <br /> _ ,_. _ _ Annular space grouted with tremie pipe <br /> - ❑ Casing Pertoration/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> t <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> . � �` Grouting Material � � �om � to f/S/� ft. yards �� bags <br /> ! vC/ <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> a <br /> from to ft. yards bags �` <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> � Other unsealed well or boring on property? ❑ Yes No <br /> LICENSED OR REGISTERED CONTRACTOR CERTI C ION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> Ibn Stodola i�e3l Drillir� Co., Inc. 27172 <br /> Contractor Business Name License or Registration No. <br /> ��.. /--�� // .. _ .�__.�-�--" - /`r .! _ <br /> /� <br /> -,_ �/! ..�� <br /> . " �-7 ` p . <br /> �lytiiqn�d, p�Esenta e Signature Dat� <br /> ......"..... .,' r ,, ��.l�::a`f'�..i <br /> �+ �j Name of Person Sealing Well or Boring�� <br /> LOCALCOPY H � � � p � p <br /> HE-01434-02 10/95R <br />