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MINNESOTA DEPARTMENT OF HEALTH M�nnesota Well and Bonng � —� 'i
WELL OR BORiNG LOCATION Sealing No !H 1,�.����
Counry Name WELL AND BORING SEALING RECORD M,��eso:a„�,q�e No —
H�nn��rin Mmnesota Sta�utes,Chapter 1031 or W-series No �
1Leave Dlank�I n�1 known�
Township Name Townshlp No. Range No. Section No. Fraction(sm.i Ig.) Date Sealed Date Well or Bonng ConslructeA
Urono li7 23 21 , N 9/17/�$
Numencal Street AdAress or Fire 1Number and City of Well or Boring Locanon ,] �y
Z 6.�� �G�pIQ �l d�� �d�� Depth Be�ore Sealmg l��7 fl. Oriqmal Depth l��3 fl.
Show exact loca6on ol N•ell or boring Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL
in section gnd with'X'. � i A'�. bcahon, showing propeny �Single Ayuder ❑ Muluaquifer
� ~ lines,roads.and bwldings.
N WELUBORING Measured ❑ EsGmatea
� � � ...w` hi
[�.Water Supply Well ❑Monit.Well
- - -T- -;-- --'-- y^��, t��tr �� ❑ Env.Bore Hole ❑Other _ �� h. �]��pN, ❑app�e Wnd suAace
W -- - -'r- -i-- --i-- E Ic,�. .,.�"_.� CASING TVPE(S)
� ���
—�- ---- -i-- -�— � �".Steel ❑ Plastic ❑Tile ❑Other
%mde
__�_ � CASING
-�-- -i-- -i--
Diameter Depih Set m oversize hdeT qnnualar space inrtiaNy grouled7
S !� ^y �[
L�i,,,,y� � in.from V to ��` ft. ❑ Yes [yNo ❑Ves ❑No ❑ UMvawn
f
PROPERTV OWNER'S NAM in.from to ft. ❑ Yes ❑No ❑Yes ❑►� ❑�^w��
Property ownefs mailmg adtlress if diflerent than well IocaUon address�ndicated above. in.from to R. ❑ Yes ❑No ❑Y� ❑� ❑U���
SCREEWOPEN HOLE
Screen irom to k. Open Hole from�to� k.
OBSTRUCTIONS
WELL OWNER'S NAME
[$Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑No ObstnkGon
Well owner's meilirg aAtlresa N diflerent�han property owner's atltlress indicated above. Type of Obslructions(DesCribe) 'y1�1$��j �i�� i�nLt �3.r�
Obstructions removed? $�Yes ❑ No Describe
PUMP
Type b1113�1�Y'.^a��71�
(iEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Otlier
FORMATION
tl nM Wiowm,intlicate esumeted fameGon bg from nearby wel�or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASINC AND BORE HOLE:
�.No Annular Space Exits
� ❑ Annular space grouted with tremie pipe
r�-L•K 2 8'7 �� ❑ Casing Pertoration/Removal
in.from to R. ❑ ��ed ❑ Hamoved
in.trom to R. ❑ PeAorated ❑ Rart�orsd
Type of perforala
❑ omer
GROUTING MATERUL(S)
Groutlng Material �Qr�r.2 a n� from �..st5,� to�� rt. yards L r1 bags
, from to R. yards b�
r�om co n. raras e.45
hom to__ fl. yards b�ps
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEAIING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes ;�No How marry/?
LICENSED OR REGISTERED CONTRACTOR CERTFICATION
-� This well or boring was sealed in accordence with Minnesofa Rules,Chapter�725_ The�fonnatio�cantained'n tltia�aport is
true to Me best of my knowledge.
�LS i�all Drilliu� 27276
Contraaor eusiness Wame Licarrss o. r.o.
.a=' � f^ ,
% , ,.� /S_� `���
Autho ed Represenfafive Si�eNie Deb
�3ames LZa3.
LOCA! !'OPY H 1416 6 9 Name ol Person Seelinp WeM a Boring
HE-01430-03 2197 R