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wE�L OR BORING�OCA710N MINNESOTA DEPARTMENT OF HEALTH Sealing No. � 199
CountyName WELL AND BORING SEALING RECORD^^���eso,a u���v� •
M�nnesota Sta�utes.Chap�er 1031 or W-senes No.
ILeave Dlank i�nol knownl
Towns ip e Township No Aange No Sechon No Frection�sm. �Ig) Date Sealed Approx ate Date Well
or Boring Consiructed
?1L� ��� G.7 �la �la �i4 �-�G . �ry r
Numencal Slreel Address or Fire Number and Cay ol Well or Bormg Localwn /
TS�� T�t Q�� �+ , � �S Depth Before Sealing f�� f ft Original Depth �f� �t
L[) \A lJt71
Show exac�localron ol well or bonng -.�� Skelch map of well or bonng StaUc Water Level Accurate
in section grid wilh��X�- �ocation.showing p�operty lines.
roads.and bwid�C9s ❑Approx�ma�e
N -
-- -;- -;- -- .,,�
r
� � . � Single Aqwfer ❑Multiaquder �a fl. � below above land suAace
i i •
_i_ _�_ -i_ � � CASING TYPE
W E
� � �
- -,- -r-
i i i � Steel ❑Plas�iC ❑Tile ❑O�her
mik...�
__ "' _!' _i_ � '.._.,J � .. ! �
i
�/,t�
S �,.t Screen Irom �'i� 10 �� fl. Open Hole from to ft
�—7 mrle--� OBSTRUCTION/DEBRIS/FILL
�`�
�Obsiruction ❑Debns ❑Fill
PROPEHTV OWNER'S NAME
/ 1:, f9
L��OIk3rd G 'r �"'�'' �ft1�F/=' 'p��' ¢ j�'' /?'1�^-
Type of debns/obstruction .� � { U /
MaJing Address�d,d�i.ff,e,�reynt,i.h,Tan,�,propeAy address i�.nd�cated above
.Attn: 4'L31..��LC�� ��.gc.� ObstrucUon/Debns/Fill removed7 Ves ❑No
C/O 1X3lC�WO� ��IO�C PUMP
12I2 �layzata Blvd �. y�/�
Wa�syt•d� 1'lL�l ��'JCJl At�s .Wb ti{,���.�.3 Removed ❑Not Present ❑ Other ,„7��� �U�!'J
�'.r. i�2�.Y1
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depih Set in overs¢e hole? Annular space ini�ially grou�ed9
If not known.mdicate estimated formahon log from nearby well or bormg. �
�l
in.from �to //��it. ❑Yes �lo ❑Yes ❑No ❑Unknown
Drift "
in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.trom to R. ❑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 grou�ed with tremie pipe
❑Casing Perforation/Removal
in.from to R. ❑Perforated ❑Removed
in.from �o n. ❑Perforaled ❑Removed
Type of perforator
❑O�her
GROUTING MATERIAL
/
Grouting matenal w lf��1L.U�from �_to �/2 ft. yards �_bags
from ro tt. yards bags
REMAHKS,SOURCE Of DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
from to ft yards bags
UNSEALEO WELLS AND BORINGS
Other unsealed well or bonng on property7 ❑Yes o
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed m accordance with Minnesola Rules,Chapter 4725.The information contamed in this report is
true to ihe best of my knowledge.
Dot3 Stodol�st��ll Dri.Il�n� ^.n , I"�c- �t��
Conhactor Busmess Name L�cense or Regrsfrabon No
�`
� 9-26-95
_-�;,, �� �,
/ d Epresentadve Sigi�at Date
Jl.r3 �I1�Oi3SOi1
�,�'�„�'� � Name ol Person Sealing Well or Bonng
HE-0�434-Ot