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wEL� OR BORING LOCarioN MINNESOTA DEPARTMENT OF HEALTH Sealing No. H �} O f
�oUn�Y Name WELL AND BORING SEALING RECORD M���eso�a u��qUe No.
��n Minneso�a Statutes.Chapter 103/ or W-series No.
(Leave blank R not knownl
To r�i ND �me _ Township No. Range No. Section Na Fraction(sm. �Ig.) Date Sealed Approximate Date Well
�Wr,�•� � or Boring Constructed
117 23 2a �,a �,4 �,� �, ;, �;� , �
.' Numenr.al Street Address or Fire Number and City of Well or Bonng LocaUon ` �, r �
�/� /�+,�,.,� p� LL (i i
,3VZ5 �,�Or3L;V � Ml ri�1 �� Mt� 55391 Depth Be(ore Sealing r � ft. Original Depih f Z��-� ft.
Show exact location of well or boring Sketch map of well or �nng Static Water Level �Accurate
in section grid with'�X��. IocaUon,showing property nes.
- �-�-"'-'�rVads' nd buii ngs. ❑Approximate
N
� � � � � /, �
-i- -i- -�- -� � ,
;j�. ingle Aquifer ❑Multiaquifer �v ft � below above land surface
i i i i --____! .,Y
_i_ _�_ _i_ _i_ � CASING TYPE
W i i i i E f
� � � � T t•
-r -�- -r- -r
i i i i ,�.�e � '� �Steel ❑Plastic ❑Tile ❑Other
i _i_ i _i_ � � ��-°' -.
_ -i� i -i- � :' ' �
f � '
. '..._.__.._�.. i: ,��_ �^'; .
S Screen from-��= to � tt. Open Hole from to fl
N—7 mi�e--� ; OBSTRUCTION/DEBRIS/FILL
Obsiruction ❑Debris ❑Fill
PROPERTY OWNEF'S NAME
Cnthy ;1cGrarm �71-0074 __
Type of debris/obsiruction�� '������/�.� �w���` � ���-���1'
-�� Mailing Address if different ihan property address indicated above. ,�y(�
Obstruction/Debris/Fill removed? I�fr'es ❑No
PUMP
�Removed ❑Not Present ❑ Other ''t�. �JU��r}
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS flF FROM TO
FORMATION
Diameter Depth Set in oversize hole7 Annular space initially grouted?
� It not known,indicate estimated formation log from nearby well or bonng. ' �
clrifL � 12 �.��n from !� to _L!; fl ❑Yes �lo ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�,No Annular Space Exists
� ❑Annular space grouted with iremie pipe
❑Casing Perforation/Removal
in.from to k. ❑Perfora�ed ❑Removed
in.(rom to k. ❑Perforated ❑Removed
Type of perforator
❑Oiher
GROUTING MATERIAL
�
Grouting material„/d_%�''���' �`�/��t r 'irom � to ��,�t`„ ft. yards �bags
from to tt yards bags
� REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
} i (�� irom to ft. yards bags
�� , .�NO ' '1
� � II UNSEALED WELLS AND 90HINGS
- �-- ' _ �� �\��'.,L-r f j��; Other unsealed well or boring on propehy7 ❑Yes �.(Vo
V
"' LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chap�er 4725.The information contained in this report is
irue to ihe best of my knowledge.
J �on Stadola WeI1 Dri11;n� c�o., Ildc. 27172
��� ��/ �9� Contractor Business Name License or Registration No.
^ � � �-- ��./J�'�-�"� (�..._ �1V-7'Y
on ed Representahve Sgnature Date
Jim Antos�son
LOCAL COPY H 4 2 9 0 7
Name ol Person Sealing Well or Boring
� HE01434-01