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MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring � ������� '. <br /> WELL OR BORING LOCA710N Sealing No. H <br /> �o���y Name — WELL AND BORING SEALING RECORD M,��esota��;q�e No �- -- � <br /> Minnesota Statutes,Chapter 1031 or W-senes No. <br /> ILeave blank i�not knownl <br /> Township Nam Township No. Range No. Sec6on No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> .�� ` i.. �/ !' f_)E J <br /> Numerical Street Address or Fre Number and City ot Well or Boring Location � , <br /> Depth Before Sealing ���-~ 8. Original Depih ��� fl. <br /> Show exact location of well or boring Sketch map of well or boring A UIFEH(S) STATIC WATER LEVEL <br /> in section grid with"X". --- -���,����.�.,location, �showing property Single Aqwfer � Multiaquifer ' <br /> lines,roads,anQ buildings. <br /> N � � WEWBORING �Measuretl ❑ Estimated <br /> i � <br /> � <br /> � � � �Water Supply Well ❑Monit.Well • <br /> --r- -� �-- -�-- r i <br /> � ' ' � Env.Bore Hole ❑Other / t^ ft. below <br /> � � � > ❑ — � ❑ above land surface <br /> y; <br /> yy -- - - -- -�-- --'-- E o CASING TYPE(S) <br /> � � <br /> � � � ... <br /> � <br /> � � � � <br /> -�-- -�-- --i-- --�-- - . � : Steel � Plastic �Tile �Other _ <br /> �mde . _ _ . . . <br /> ' ' ' ' � �. � CASING <br /> --�- -�-- --�-- --�-- <br /> � Diameter Depth , Set in oversize hole? Annualar space in�tially grouted? <br /> ��i mna��, ��� !:��—��LL� � �/in.from !�..� to C � tt. ❑ ves `�j No ❑ ves ❑ No ❑ unknown <br /> `r, - <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Property owner's mailing address if diNerent than well location address indicated above. in.trom to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> / � �/ � <br /> Screen from �/� ro�.,�._ tt. Open Hole irom to R. <br /> OBSTRUCTIONS <br /> WELL OwNER'S NAME Rods/Dro Pi e <br /> p p ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> .�_ / <br /> Well owner's mailing address if diHerent than property owner's address indicated above. TypB Of ObSt�uctions(Desc�ibe) �l��✓!� '� ��-�%�T� � /""< ��/ fj'�-�//i f <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP <br /> Type ._f;:r�.�/�i�i;__ �. / F! /�%� i� .. . , - <br /> GEOLOGtCAI MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> tl 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 /> No Annular Space Exits <br /> ? 1 <br /> _., , ❑ Annular space grouted with tremie pipe � <br /> �j ❑ Casing Pertoration/Removal <br /> in.trom ro fl. ❑ Pertorated ❑ Removed <br /> in.irom to ri. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> �� � , <br /> Grouting Matenal� "�"�' ��'f��'{Trom �-= to�_ ft. yards � bags <br /> from to R. 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�f No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well oi 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 /> Don Stodvla �1eI1 Drilling Co. , Inc. 27172 <br /> (�. Confractor Business Name License or Regisfratlon l70. <br /> 1 �1., . <br /> �R 3 ._ <br /> . , <br /> . , <br /> _<<f f_ <br /> f 6,r`� :�.'�`�,!'��y y <br /> ✓' -� <br /> Authonzed Representative Signature Date <br /> H 13 4 916 Name of Person Sealing Well or Boring <br /> LOCALCOPY <br /> HE-01434-03 2/97 R <br />