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