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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnes�ota Well and Bonng �H 14 l 5 2 9 �
ry WELL AND BORING SEALING RECORD Sealin No.
Coun Name �Q Minneso:a Unique No. —
`ennipen rD M�nnesota Statutes.Chapter 1031 or W-series No �
ILeave Dlank il not known)
Township Name Township No. Range No. Section No. Fracuon�sm.-s Ig.) Date Sealed Date Weli or Bonng ConsVucted
1 tE 23 36 4�-1��:�i � �
Numerical Street Address or Fire Number and Ciry of Well or Bonng LocaGon ay / f �
G t Ch��,�� (.��5@' ��1t7�� (lila�/2atd DepthBeforeSealmg � 1..�ft. OriginalDepth /�� R.
Show exact location ot well or boring Sketch map of well or bormg AO IFER�S) STATIC WATER LEVEL
in section� c, bcation. showing Yproperty Sin le A uiter
�5�(�'� g q ❑ Multiaqwter
6nes,roads,and buildings.
WELVBORING Measured ❑ Estlmated
'�._.2-�: 'r, : _ � C .
Water Supply Well ❑Monit.Well �
� ❑ Env.Bore Hde ❑Other ��,�R. �below ❑above IarW surtace
a�✓..)�L 1
W -�r- - - - — --i— E _ -- - -- CASING TYPE�S)
--f- ---- -;-- ---1-- � Steel ❑Plastic ❑Tile �Other
1 'b mile �
__�_ � CASING
-i-- -�-- --i--
Oiameter Depth � Set in oversize hWe9 Annualar space inrtially grouted?
S 1� ��
��,,,;�,�y fn.from v to � �� n. ❑ ves �No ❑ ves ❑No ❑Unkrawn
I
PfiOPERTY OWNER'S NAME in.trom to k. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
rU�@ B1ct11tL � 1�r .�. '— �
Properly ownefs mailirg address if different than well locatlon address mdlcated above. in.trom to ft. ❑ Yes ❑No ❑ Yes ❑No ❑Unknown
SCREEWOPEN HOLE
,�// '��' /
� Screen from�to J��L ft. Open Hole from to R.
OBS7RUCT10NS
WELL OWNER'S NAME Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑ Fill ❑ No Obstruction /�
WeN owr�s meiling address if diMerent than property owner's adtlress indicated above. Type of Obstructqns(DOScribe) .-.L-1V��� !�� Q / U/�i�
Obsirudions removed? Yes ❑ No Describe
PUMP
TY� ��� ��m�
OEOLOOICA�YATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Ofher
FORMATION
M nd known,irWicate estimated tortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINCaS,OR CASING AND BORE HOLE: �
.,/ �No Annular Space Exits
(..,�} .et...
❑ Annular space grouted with tremie pipe��,
4 ❑ Casing PeAwation/Removal
in.hom to ft. ❑ Pertaated ❑ Rertaved
in.from to it. ❑ PeAaated ❑ Removed
Type of perforata
❑ other
GROUTING MATERIAL(S)
� r�/� � /��,y��,./�'�� i
Groudng Material,�.sr-�._t'��lL""►r6m � to��ft. yards �_ begs
from to It. yards b�s
from to R. yards begs
from to_— fl. yards begs
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIRCATION
�� � � � This well w boring was sealed in ecoordence with Minnesota Rules,Chapter 4725. The i�fortnation oontained in Crs repat ia .
true ro the best of my krawledge. �
� - DGId S�'aDCLh �tELL DFLTLLSRIG CO. , 1N{:. ?.7 1/:�
Contractw Business Name Licgnse or Reyrstratiorr lio.
a ��f:�..;;\,.� � ! �`
._ � - -�;�''r`�� . , �/ � > . %;"J
, fefrv9 Signe(ure 09M
`� � _��..,s,.,�~
��`a ,,,-.- �"�..J
LOCAL COPY H 1�l 5 2 9 Name al Person Sealiny ,eM a Baing
ME-01�31-03