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WELL OR BOFiNG LOCAnON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring j ���{��� � <br /> Counry Name WELL AND BORING SEALING RECORD Minnlesota Unique Well No. I H— a-- <br /> Mmnesota Sratu�es.Chapte�1031 or W-series No. � I <br /> . `lt 1+..��,.�,,, �Leave Clenk H not krawn) _ _J <br /> Township Name ,.Townsh�p No. fiange No. Section No. Fr,� on,(sm.-i Ig.) Date Sealed� Date Well or Borirg Constructed <br /> l `f��/ r f --. <br /> I� �� � > •= :. F3`' T n"% t .�`.. � �� <br /> Numencal Sireet Address or Fire Number and Gty of-yYVell or Bonng localion �� - '- <br /> � •�' � � :'�`� Depth Before Seahng � ' R. Onginal Depth h <br /> . - f 'f( ----�— <br /> Show exad IocaLon of N•ell or bonng / Sketch map of well or bonng AOUIFER(S) STATIC WATER LEVEL <br /> in section gnd wrth"X". location, showing property �'Single Ayurfer � MWUaquiter <br /> lines,roads,and buildings. <br /> N WELL/BORING (i�Measured ❑ Esumated <br /> __ �__.: � <br /> � �Water Supply Well ❑Mona Weu � <br /> - - - -- -- -- - -- ' {� <br /> � ❑ Env Bore Hote ❑Other �fl. ❑below ❑ above land surface <br /> _ I I I <br /> ; W -r- -�-- -�- --�- E ...�_..___.._..,r-' CASING TYPE�S) <br /> --;-- -;-- --;-- —�-- � �yf [j Steel ❑ Plastic ❑T�le ❑ Other_ <br /> � � � }�mile � ;�/ <br /> --- --- -�-- - - � CASING(S) <br /> �`r � � Diameter Depth Set in oversize hoie9 Annular space initially grouted? <br /> �r mde�e ��-�-�^•^�'"�'� � �; m.Irom to JJ f"`I ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> I <br /> PROPERTV�OWNEA'SNAME,r -�_� m.from to ft ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> ' ," .e. [jr � , .. : �,,`r F <br /> Property owner s mailing ad ess i diflerent than well location address intlicated above. m.irom to � R. ❑ �es ❑No ❑ Yes ❑No ❑ UnknOwn <br /> � -/ <br /> " ' ,'',3 ��j�`1.,s'-t.-"�C.� _ .� <br /> , � � � , /� SCREEWOPEN NOLE <br /> l <br /> � '" Screen from � to �F�' ft. Open Hole irom to tt. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> W811 owners mailing address if difleient than property owner's atldress indicated above. Type Of ObStruCliOns(D65Cfibe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP f <br /> Type <br /> GEOLO(iICAL MATERIAL COLOR HARDNESS OF FROM TO Q�Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If rwt known,indicate estimated formatwn log hom nearby weli or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING ANO BORE HOLE: <br /> ❑No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to tt. ❑ PeAorated ❑ Removed <br /> in.from to n. ❑ Perforated ❑ Removed <br /> Type of pertorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag oi bentonite=50 Ibs.) <br /> � <br /> Grouting Material �'' from to � tl. yards bags <br /> from to tt. yards bags <br /> irom to tt. yards bags <br /> from to__ ft. yards bags <br /> REMARKS.SOURCE OF DATA,OIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes ���No How many? <br /> LICENSED OR HEGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information co�tained in Mis report is <br /> true to t�e best of my knowledge. <br /> . . . _. %.C. . . <br /> Contracror Business Name f� License,w Registretion!'a. <br /> . �- <br /> X f�' � <br /> . �. <br /> AuMorized Representative Signature Dete <br /> i <br /> :,�e!L-E <br /> H ����A� Name o!Person Sealing Well or Bonng <br /> LOCAI COPY i <br />