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' wELL OR BORING LOCA7iON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12 4 5 6 3 <br /> County Name <br /> WELL AND BORING SEALING RECORD MennlesoNa Unique No. <br /> enne �.Ii Minnesota Statutes,Chapter1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-►Ig.) Date Sealed Date Well or Boring Constructed <br /> ronu l I7 23 17 44-t�OZ j� �;,�F <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location ~ �, � <br /> 4��J Da�Q�eQ T�SL'e 3 OrQIIO 5 S 392 Depth Before Sealing '���Z-� ry. Original Depth � ft. <br /> Show exact location of well or boring Sketch map of well or boring A�UIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". ; location, shawing property Single Aquifer ❑ Multiaquifer <br /> lines roads,a b ildings. <br /> N :'i�, � '��� - ���`�..�. W UBORING �Measured ❑ Estimated <br /> � � � �._ Water Supply Well ❑Monit.Well � <br /> -i-- -i-- �,/ <br /> 4�� ❑ Env.Bore Hole ❑Other �ft. I�below ❑ above land suAace <br /> � � � � __..._.�...__._..._.._._.__ <br /> W —�- -�-- -i-- --i— E CASING TYPE(S) - <br /> � � <br /> � � <br /> � � � � , <br /> --�- -�"- -�-- --�-- � �.Steel ❑ Plastic �Tile ❑ Other <br /> Y.mile <br /> --�- -�i-- -�-- --1— � ._.._,,,,,,,,,,,,,_._..___.._....._ CASING <br /> , Diame�� . Depth f Set in oversize hole? Annualar space initially grouted? <br /> 1 S 1 """��J��� '1 /� <br /> �r m��e--q�, �7 � in.from S� to Z� � tt, ❑ Yes �No ❑ Yes ❑No ❑ Unknown <br /> I <br /> ROPE T OWNER' NAME in.irom to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> �an�`�at �urneic�e �20-9466 <br /> Properry owner's mailing address if ditterent than well location address intlicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> i <br /> !1 ;`: ,� ,y�'�, Screen from �� f to ��� ft. Open Hole from to R. <br /> J <br /> OBSTRUCTIO WDEBRIS/FILL <br /> WELL OWNER'S NAME �Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if diHerent than properry owners address indicated above. Type of ObStructioNDebris/Fill �/�1�/f�`�� / .�/�� �' �1/�1�� <br /> Obstruction/Debris/Fill removed?�Yes ❑ No <br /> PUMP <br /> Type �U� /-!1/�� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � _ i •'i <br /> No Annular Space Exits <br /> i,�) �.:�cX. <br /> � � ❑ Annular space grouted with tremie pipe <br /> �,'f ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material ���/��� /��•f✓1��m � to� ft. yards �_ bags <br /> from to ft. yards bags <br />�� from ro R. yards bags <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 o <br /> LICENSED OR REGISTEREO CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this repoR is <br /> true to the best oi my knowledge. <br /> Don Stodola W�II Drilling Co., Ine. 27172 <br /> Contractor Busmess Name f License or Registrallon No. <br /> _..--� , f <br /> ,�/' -� ��f 1 <br /> ,%�j,�.�'�f l i��i ti':. i �` ! <br /> Aut�rl ed Representative Signature Date <br /> •; <br /> - �,.', �1 -{�-. <br /> ��' �. ,1.t.�_ `, �y..,._;v`-�. <br /> LOCAL COPY H <br /> 12 4 5 6 3 Name ol Person Se¢ling Well or Bonng <br /> HE-01434-02 10/95R <br />