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MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ���/�^�� � <br /> WELL OR BORING LOCAT�ON I <br /> County Name WELL AND BORING SEALING RECORD Sealing No. �H L �_ <br /> Minnesota Unique Well No. i- — — � <br /> �;� M�nnesota Stalutes,Chapter 1031 or W-series No. <br /> ,?1 Tt�!�)�.i T �,e,�,d�x n�a k�.,�� -- <br /> Township Name Township No. Range No Section No. Fraction�sm.-►Ig.) Date Sealed Date Well or Boring Constructed <br /> t�rc�n� I17 23 ?� �1-0£���. � %�,�,' J�. <br /> Numencal Street Address or Fire Number and City of Well or Bonng Location �, � , <br /> �. r� i/ `g � <br />�-� �1�� �.c`r'..��3 4.�� � j�rn�n DepthBeforeSealing_r'�` ___tt. OnginalDepth _ ,_�r..t% fl <br /> Show exact location of v.�ell or bonng Sketch map of well oi boring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing prpperty mgle Ayuifer � Multiaqwfer <br /> lines,roads,and bwldi�gs. <br /> N WELUBORING �Measured ❑ EsUmated <br /> � <br /> � - <br /> � � � � "'����� �`Water Supply Well ❑Monrt.Well <br /> -�- -;-- --;-- —� <br /> -- �� , � � ^"t �," <br /> ,*:r � .,� ❑ Env.Bore Hole ❑Olher __ _ H. �below ❑ above land suriace <br /> yy —�- - — - -- --i— E . . ..__...._._.... . � CASING TYPE(S) <br /> � � <br /> � � � <br /> � � � � � <br /> � � � <br /> � � � � <br /> . —�- -�-- -i-- —�-- � � �teel � Plastic �Tile � Other <br /> � <br /> � � � � }4mile � � � <br /> � � � � � _ �._.___.�. CASING(S) <br /> -�-- -�-- -�-- --�-- <br /> Diameter Depth Set in oversae hole� Annular space initially grouted? <br /> S """111��� � ,�, i y .� ` ' � <br /> �t,—r mi�e—q. � in from �� to t"'�r'� tt. ❑ yes No ❑ Yes ❑No ❑ Unknown <br /> I I <br /> PROPERTY OWNER'S NAME in.from to ft ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> � / <br /> PropeRy owner's mailing�address if diflerent than weil lowfion atldress intlicate0 above in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> ���c ��&£y Fy� SCREEWOPENNOLE <br /> y ) s x I <br /> ) t L Jtti <br /> '.�_'�(3 e t] p�'$1��,�� �`�°!T rj 5 3 Y�} . - Screen from �"�'7 to �� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No ObsVuction <br /> Well ownei s meilin address if diBerent than r owner's aetlress mdicated above. �� " �� � �� <br /> 9 P�M Type of Obstroctions(Describe) � �d�!�����- Js���/� t �����/��'1�' <br /> Obstructions removed? [�l'es ❑ No Describe <br /> PUMP <br /> TYPQ 'f j.:? 1�'ll;i?)�-;% <br /> GEOLO(iICAL MATERIAL COLOR MARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formatbn log from nearDy well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space 6cists <br /> ; ��' ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from ro ft. ❑ PeAorated ❑ Removed <br /> in.}rom to ft. ❑ Pertorated ❑ Removed <br /> Type of periorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=501bs.) <br /> r-, t _,,.. � <br /> A� � . ; <br /> Grouting Material L'��� '-� ��r` �frdm '�-�� to� ft. yards � � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to— ft. yards bags <br /> REMARKS,SOURCE Of DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIfICATION <br /> This well or boring was sealed in accordance with Minnesota Fules,Chapter 4725. The information co�tained in Mis report is � <br /> true to the best of my knowledge. <br /> �.c�r� °St��3�I;.� i�e1�. �rillin;; C�, , Inc. 2717� <br /> Contracror Business Name . � License or Regishatlon I'ro. <br /> ��� �'�.. f: <br /> � ! � , <br /> Authorized Represenfative Signature Dafe <br /> H ������ Name o!Persar Sealiny Well or Bonng <br /> LOCAL COPY <br />