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MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ������ �
WELL OR BORING LOCATION Sealin NO. I H
Gounry Name — WELL AND BORING SEALING RECORD 9 -- --�
Minnesota Unique Well No. I� --— �
������� Minnesota Statutes,Chapter 1031 o�W-�sMe„as No.
Township Name Township No Range No. Section No. Fracuon(sm.-�Ig.) Dale Sealed Date Well or Bonng Constructetl
�rnao 11? 23 7 . ,. �"_ .�% ;'- s'�"c.'
Numerical Sireet Address or Fire Number and Ciry of Well or Bon�g Locauon
l�f!$ H4�th A13 DY j 41't73� $��� Depth 8etore Sealing_� �� 8 Original Oepth ___h
Show exact bcation of N-ell or boring Sketch map ol well or bonng AOUIFER(S) STATIC WATER LEVEL
In section gnd with"X". location, showing property Sngle Aywfer ❑ Mulhaquifer
� lines,roads,and buildings
N ' WELUBORING �Measured ❑ Estimated
s',.
- -- -- -- - -- ,� • �later Supply Well ❑Monit.Well
:" ❑ Em.Bore Hole ❑Other _ ___�7_�ft [�below ❑ above land surtace
i
. W __f_ _,__ _l__ __l__ E : . �::.
�. CASING TYPE(S)
-;-- -;-- , --i- � ' f�Steel � Plastic �Tile �Other
� � � � �mile �....._.�- r
—�- -�- -�— --�— � F/` CASING�S)
t
Diameter Depih Set in oversize hole7 Annular space initially grouted?
5 4
��m,ia� '� m trom � to� n. ❑ �es ❑No ❑ ves ❑No �Unknown
PFOPERTY OWNER'S NAME in.irom_ to ft. ❑ Yes ❑ No ❑ �es ❑ No ❑ Unknown
• Joht� iTalker
Pioperty owner's maihng address if different than well location address indicated above. in.from_ to .ft. ❑ Yes ❑ No ❑ �es ❑ No ❑ Unknown
1'�1{i �J'��LEGw� �l��C� SCREEWOPENHOLE
► �� ..�
�1"�O� i� 5536� Screen from�-��✓to�� ft. Open Hole from ro k.
OBSTRUCTIONS
WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �No Obstruction
JOhn WSI.�te�
Well owner's mailing address if diHerent than property owner's atltlress indicated above. Type of ObStrodions(DOSCfibe)
- s�� Obstructions removed? ❑ Yes ❑ No Describe
PUMP
7ype �\.J��, �e"'���{jl � �.
GEOL061CAL MATERIAL COLOR MARDNESS OF FROM TO y�Removed ❑ Not Present ❑ Other
FORMATION
- If not known,irWicate estimated tortnatbn log from nearby well o�bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
`�.No Annular Space Euists
r �
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
� in.from to tt. ❑ PeAorated ❑ Removed
�'
• in.from to fl. ❑ Perforated ❑ Removed
Type of perforator
❑ omer
�� GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Matenal ���'-� t ����f�om � to�.�. yartls bags
from to R. yards bags
_ from to .ft. yards bags
from to_ ft. yards begs
REMAIiKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS
�,�
Other unsealed and unused well or boring on property? ❑Yes .�No How many?
LICENSED OR REGISTEHED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information coniained in this repoA is
true to Ihe best of my knowleclge.
Stevens I?rillinQ � Eav_ ServiceR g(�65�.
Contractor Business Name.. License a Regisfretion 170.
. � -. ��: ..—'_
a , � . �'`'-�'� __� � _', /,?
S � -
AuMorized Representative Signature Date
..� �.: ��• + � k'`;� C�....,;", �1,
. n 16 3 4 7 7 Name ol Persoo 3epling Well or Boring .