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MINNESOTA DEPARTMENT OF HF_ALTH Minnesota Well and Boring ��a A�f� �
WEIL OR BORING LOCATION I
County Name — WELL AND BORING SEALING RECORD M;��'e90 a u��q�e we��No. !H— r,�j}- �
Minnesota Statutes.Chapter 1031 or W-series Na � �
ti.ev.dar�x n nm knownl .
Township Name �Township No. Fange No. Sechon No. Fracuon�sm.�Ig.) Date Sealed Date Well or Bonng Constructed
�tOAt� Z�7 �� �� ��.'{��� 2
Numencal Street Address or Fi�e Number and Ciry of Well or Boring LocaUon /y,��S � /��// /
3245 Car��� �� V� �� Depih Bebre Seahng ` V�� N Original Depth _ ��L_n
Show exact location of well or bonng Sketch map ol weil or bonnq ApUIFER(S) STATIC WATER LEVEL
in section gnd wRh"X". locauon, showing property Single Aywfer ❑ Mul6aqwfer
lines,roads,and buildings.
N WELUBORING Measuied ❑ Estimated
;. �- Water Supply Well ❑Moni�.Well �"//� �
j I , -I-_ � ❑ Em.Bore Hole ❑Other !L,L_ft. �below ❑ above land surtace
W --�' '�'" -�'- - E CASING TYPE(S)
,
� i � � ....k,.....-f.<
---- -�- -i— --�— � �'-� � Steel � Plastic �Tile �Other
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� � }�imila �.- �t�
____ '�" '�" __�__ � ,,��. CASING(S)
� Diameter Depth � Set in oversrze hole? Annular space initially grouted?
�i mne—q. �,.� _L1— in.irom� to��ft. ❑ Yes �No ❑ Yes ❑No ❑ Unknown
i
PROPERTV OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ Ves ❑No ❑ Unknown
.�
PropeAy owner's mailing adtlress�f i erent than well iocation address indicated above. in.trom to fl. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown
SCREEWOPEN HOLE
f �}� /`/
Screen from ` � �`�' ro I$7 ft. Open Hole from to R.
OBSTRUCTIONS
WELL OWNER'S NAME Rods/Dro Pi e
p p ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owneYs mailing address if diHerent than properry owner's address indirated above. Type of Obstruclions(Describe) ��w�� f.Ja�= �" �C�
Obstructions removed? �Yes ❑ No Describe
PUMP
Type
6EOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
• �lo Annular Space 6cists
�.w fY�
❑Annular space grouted with tremie pipe
❑Casing Perforallon/Removal
in.from to tt. ❑ PeAorated ❑ Removed
in.irom to ft. ❑ PeRorated ❑ Removed
'
Type of perforator
❑ Omer
GROUTING MATERIAL(S) (One bag of cement=94 Ibs„�one bag of bentonite=50 Ibs.)
Grouting Matenal �E�F ��/�+�`^'�from '+� �to�k. yards � bags
from to R. yards bags
from to ft. yerds bags
from to__ ft. yards bags
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes No How many?
LICENSEO OR REGISTERED CONTRACTOR CERTiFICATION
This well or boring was sealed in accordance wiM Minnesota Aules,Chapter 4725. The information co�tained in this report is
true to the best ot my knowledge.
�n Sied+al.a iiellDrillittg �s�. , Inc. 27172
Contractor Business Name � License a Registretion Yvo.
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p senfa rve Si nefure '- Dafe
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^���! .7'"'r"Y."" ��.✓ '"-.J'v^"`�"e'/'y'4`"'�`�"_'
u ������ Name ol Person ny Well or Bonng
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