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e WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring � w �/���� �
` ---- WELL AND BORING SEALING RECORD sear�9 rvo. i H 1 ` _
j Cou�ry Name Minnesota Unique Well No.
; Mmnesota Statutes,Chapter 1031 or W-series No. I
Henaepin 0.�.mmc n�a knownl __. _ �J
' Township Name I,Townsmp No F na ge No Secnon Na Fract�on�sm.-s Ig.) Date Sealed Date Well or Boring Consiruded
' rono � 1 I 7 �3 f37" i��4-t�'12
Numencal Street Adtlress or fire Number and Ciry of Well or Bonng Locaiion �
/
_��! 8����� ���� 4��� Depih Before Sealing � fl. Original Depth�_ h�
Show exact location of N-ell or boring Sketch map of well or bonnq ApUIFER(S) STATIC WATER LEVEL
in section gnd wrth"X". IocaUon. showing propeny Single Ayuiter � Multiaquder
Gnes,roads,and buildings.
N WELUBORING �Measured ❑ Estimated
.Water Supply Well ❑Monit.Well
_ _ _Y_ _ __ __ __ ,,/�.���
i` ❑ Ern.Bore Hole ❑Olher _ L/'�`�"�"F R. I�below ❑ above land surface
W --�- -i— -i-- --i-- E � CASING TYPE(S)
� � � �
� � � �
—�- -;-- -;— --�-- � X�Steel � Plastic �Tile � Other
Yzmile r
—�- ---- -,�-- --�— � CASING�S)
Dlameter Depth t Set�n oversize hole7 Annular space initially grouted7
S �. 7 /l /'�
k—1 mile� _,(,��_ in from V to� R ❑Yes �No ❑ Yes ❑No ❑ Unknown
�
TV S NAME m.irom to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
`���. �`�,e 3�Q—�b�3
Property owner's mailing atldress il dlflerent than well location address indicated above. m.�rom to k. ❑ Ves ❑ No ❑ �es ❑No ❑ Unknown
�!(/�i .aigQ�$S i!l�j�a SCREEWOPEN HOLE
� ����a����a� � ����� Screen from_'�c�_���to��,R. Open Hole from to R.
OBSTRUCTIONS
WELL OWNER'S NAME �ods/Dro Pi e ( ) ❑Debris Fill
p p ❑ Check Valve s ❑ ❑No Obstruction
Well owners mailing addreu if AiffereM than properry owner's address indicated above. Type o(Obstruc�ions(Describe) ������� ./� 4 ���
Obstructions removed? �Yes � No Describe
� PUMP �+' �'} - .. � � � � .
Ty� ��� f !'��
GEOL061CAL MATERIAL COLOR HARDNESS OF FROM TO emoved ❑ Not Present ❑ Other � � �� �
FORMATION
It not known,indicete estimated fortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�'�Jo Annular Space Exists
� ��
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.irom to ft. ❑ PeAorated ❑ Removed
Type of peAorator
❑ Omer
_ _. --- -- ------ - ----------
. . .. - — � - � -- -- -- --"-•
r Grouting Materiai �'� � �"� ��� to�'n yards __�.__ bags �
f�� to R. yards bags �
from to R. yards �9�
from to-- �� yards ba<y-:
i
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS d
� � Yes No How many? '
Other unsealed and unused well or boring on property. ❑
UCENSED OR REGISTERED CONTRACTOR CERTIFICATION
�� This well or bonng was sealed in eccordance with Minnesota Rules,Chapter 4725. The information contained in this report is
�true tc'he best o?my knowledge.
Don S�odola �1eI1 �rillin�_Go., Inc. 27172
- ----- °.
t —""—�--- License Or Registretion�vo.
Can�ra-tor8us ��`��^'?
__ � / Q�
�- oere
d �asentativa Signaturet� .
LOCAL�OR`� H ��n�O� Name ol Person a ng Well or Bonng
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