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� <br /> -� - - <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i --������] � <br /> - WELL AND BORING SEALING RECORD Sealing No. H J <br /> Councy ame Minnesota Unique Well No. � — � <br /> /j Minnesota Statutes.Chapter 1031 or W-series No. <br /> (Leevs tlank M nd krawn) <br /> Town hip Name ownship No. Range No. Section No. Fr llon(sry.,-�Ig.) Date Sealed Date Well or Boring Consiructed <br /> ,��, �� �� � � �y� � <br /> umerical�Street Atldress�Fire Number and Gry of Well or Boring LocaUon � — <br /> 1� j� Depih Bebre Seahng f� j N. Original Depth h <br /> 1 <br /> Show exact location o N�ell orb ing Sketch map of well or bormg AOUIFER(S) STATIC WATER LEVEL <br /> in section grid wrth"X'. � location, showing property 'Smgle A�uder � MulUaquAer <br /> lines,roads,and buildings. ' <br /> N WELUBORING �'Measured ❑ Estimated <br /> � �Water Supply Well ❑Monit.Well � <br /> -Y- ' <br /> ❑ Env.Bore Hole ❑Other _ tt. ❑below ❑ above land surtace <br /> W —�- - — -i-- --i— E � -'�\ CASING TVPE(S) <br /> � --'-- <br /> � <br /> � <br /> � . <br /> , ��.� � <br /> —�- ---- -i-- --�- � /1� � �;,Steel ❑ Plastic �Tile �Other <br /> ' Y2mile �(/ �"L . <br /> i i i � �� <br /> —�- -�-- -i-- --�— Y ::_,.; CASIN(i(S) <br /> � Diamete� Depth Set in oversize hole? Annular space initially grouted? <br /> S /' /` f'�1 Yes No Unknown <br /> �r m;�� J f' /.�A(� �_..�! _� m.�rom to,�/L'� n. ❑ ves ❑No ❑ ❑ ❑ <br /> .dgF /l�d�y. Yw` <br /> PRQP�TV OWNER'S NAME �� in.from to R. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> � <br /> .E . <br /> Property ownei s ma ng addres's if dIM ent t a`n wel ocafion address intlicated above. in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> f f�� � SCREEWOPEN HOLE <br /> �o'� � P��.. `�V �f <br /> �� � � Screen from_._.�rG�,J to�� ft. Open Hole from to tt. <br /> ;> X�� „ � � �} �� OBSTRUCTIONS <br /> WELL OWNER'S N E ❑ Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑ Fill ❑No Obstruction <br /> � <br /> Well owneYs mailing addreas if diHe�ent than properry owner's atltlress intlicated above. Type ot Obslructions(Describe) <br /> Obstruclions removed? ❑Yes ❑ No Describe <br /> PUMP /j <br />� TYPe s, f�+. <br /> (3EOLOOICAL MATERIAL COLOH HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> N not krawn,indicete estimeted tortnatbn log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ❑No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing PerforaHon/Removaf <br /> in.from to ft. ❑ FeAorated ❑ Rertroved <br /> " in.from to ft. ❑ PeAorated ❑ Removed <br /> Type of peRorator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> i ' � . ,�a <br /> GroutlngMaterial �y���"�"'��from r r ] to f ..� fl. yards �— begs <br /> from to ft. yards bags <br /> from to tt. yards begs <br /> from ta__ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property7 ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOH CERTIFICATION <br /> This well or boring was sealed in accordance with MinnesoU Rules,Chapter 4725. The infortnation contei�ed in this report is <br /> true to th�best of my�lowledge. � <br /> � <br /> /� � � i , <br /> � � � ��� � � <br /> Contrador Busi ss Neme �' Lioense a Repshe I'vo. <br /> ;r� � <br /> � i J <br /> t <br /> � 'ra - ,� i �/� <br /> � AuthonzbdYiepre -ntative Signafwe � '�Dete <br /> �� � <br /> �` , r ,f[As <br /> � �,,f .'�tl.F.ifrl �_Y�� l <br /> LaGAI.�'i9i'Y H 1��0 4 9 Naml o/Pe Sealing Well or Boiing ' <br />