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�_ _. . __ _ <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i ��1 ��� � <br /> WELL AND BORING SEALING RECORD Me�;;e90 a u�;q„e we��No. �H �' <br /> Counry Name — <br /> Minnesota Statutes.Chapter 1031 or W-series No. �_ I <br /> (L�ew tleNc X iwt krawn) � <br /> � Township Name Township No. Range No. Section No. Fracuon Ism -►Ig� Date Sealed Date Well or Bonng Constructetl <br /> Q=Ofl0 ��.7 �� d� ��� 3d �C� 't <br /> . Numencal Street Address o�Fue Number and Ciry ol Well or Bonng Location l q <br /> L g�# � ��g�.� �� � 4 Depth Betore Seahng f�` , N Oiig�nal Depth �1� ` _—h <br /> �f�7 J .7 <br /> Show exact locat�on of h-ell or boring Sketch map of well or bonng AQUIFER�S) STATIC WATER LEVEL <br /> in section grid wrth"X" location, showing property Single Aquder � MultiaquAer u <br /> lines,roa buildings. WELUBORING �J Measured ❑ Esumated <br /> N .�--,.��.��5`-si... �.� ^ <br /> �Water Suppry Weli ❑MONt.Weil � ,/ <br /> ❑ Em.Bore Hole ❑Other _ _{�"�� tt. �below ❑ above land surface <br /> W —�- - -- -i-- —i-- E __ CASING TYPE(S) <br /> � � � <br /> � � � <br /> '� -i-- -�-- -i-- --�- � �Steel ❑ Plastic ❑Tile �Other <br /> yimik� <br /> -'-- -�-- -�-- --�-- � CASING(S) <br /> Diameter Depth � Set in oversrze hole� Annular space initially grouted? <br /> l� S /� � <br /> µ--�mNe� ..�,.y,'a�" � y,�y,}t',y� �( � in.trom � to� ft. ❑ Yes No ❑ Ves ❑No ❑ Unknown <br /> � - n. <br /> PROPERTV OWNER'S NAME in.from to fl. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> Property owner's mailing address d ditterent than well location address ind�catetl above. in.frOm to ft. ❑ Ves ❑ NO ❑ �es ❑ No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> ��/� r �2� � <br /> Screen t�om_�r�to 1 LL.� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction <br /> Well ownels mailing address it diHerent than property owner's address indicated above. Type ot Obslructions(DesCribe) ��A/j��!i ��� a ��/ <br /> Obstructions removed? �(Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed Not Present ❑ Other <br /> FORMATION <br /> It not known,iMicate estimated tormatbn log from nearDy well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> "�No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> in.from to fl. ❑ Pertorated ❑ Removed <br /> Type of peAorator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag oi bentonite=50 Ibs.) <br /> /V N/Q T �L�I?��{,/�/ 4� ? f / <br /> Grouting Matenal from to 1�-- fl. yartls +� bags <br /> from to tt. yards bags <br /> irom to fl. yards bags <br /> from ro__ fl. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Olher unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATIQN <br /> This well or boring was sealed in accordance wiM Minnesota F�ules,Chapter 4725. The information contained in this repoR is <br /> true to ihe best ot my knowledge. � <br /> Ik�n Stod�3.aWe11 Dri113n� Co, Inc. 27I72 <br /> �'��� Confractor Business me License a Regisfrefion/'ro. <br /> �t <br /> �V�2 <br /> uth zed resen ative Sigri� Dete <br /> .��.f� At3�EitlSdtf <br /> e /��/��� Neme ol Person Sealing WeII or Bonng <br /> H �.v v <br />