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_ _ ___ _ � �� _ _ _. � _ , , <br /> MINNESOTA DEPARTMENT OF HFALTH M�nnesota Well and Bonng � j�� y�/j� <br /> WEIL OR BORING LOCATION Sea��ng No. H �"T.,/ F <br /> Counry Name WELL AND BORING SEALING RECORD Mmneso'a Unique No. — <br /> Hennep�a Minnesota Statutes,Chapter 1031 or W-senes No � <br /> ILeave Dlank i�nut known� <br /> Township Name Township No. Range No Sec6on No. FracUon(sm.i Ig.) Date Sealed Date Well or Boring Constructed <br /> OrOI30 1.�7 2.":; 03 ��+'+fl� � �-i.. �c �'f� <br /> Numencal Street Address or Fire Numbe�ryand Gry ol Well or 8ormg Locauon t / , I� f <br /> 21�IA Shevl in IJr� 0���0 5 5 39I Depth Before Sealing /r � R Original Depih f ft <br /> Show exact location of well or boring Ske[ch map of well or bonng A U ER(S) STATIC WATER LEVEL <br /> in section gnd with'X'. location, showing property r��91e Aquder ❑ Multiaquder <br /> lines,roads,.end,bwldmgs. <br /> N ,_)r EIUBORING �AAeasured ❑ Estimated <br /> � ! �ater Supply Well ❑Monit.Well � � <br /> -i-- -- -- j <br /> � ❑ Env.Bore Hole ❑Other _ � h. ❑,�Iow ❑above land surface <br /> W r � �-- --�-- E ING TY E(S) <br /> , , , , • CAS P <br /> _.._.�_____:__. , <br /> --F- --- i �-- � ; '�� ❑�ee� ❑ Plastic ❑Ti�e ❑Other <br /> � � u mrle � _,r � i <br /> `- -�-- -�-- --i-- � ._....,�.,...., � ... _. � CASING <br /> Diamet�er Depth ! Set in oversize hde? q���e NtipaYy groulEy? <br /> S y` � /� <br /> �—�^';�—.�+ l��.(� _l_ n.trom S� to /��ft. ❑ Yes ❑� ❑ves Q No ❑Unknown <br /> PR LCL7TJ�Y'lGIIlSE �}���7g�V in.from �o fl. ❑ Ves ❑No ❑Yes ❑No ❑Unlv�own <br /> Property ownei s mailirg a0tlress B tliHerent than well locat�on address mdicated above. in.f rom to R. ❑ Ves ❑No ❑Y� ❑� ❑��� <br /> SCREEWOPEN HOLE <br /> � /�/ <br /> Screen from�..,,j_to�� ft. Open Hole from to (L <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME [�ods/Dro Pi ( ) ❑ Debris ❑ Fill �Obstruction <br /> p pe ❑ Chedc Valve s <br /> WeN owners rtiaYing eAdress it Aiflerent than propeAy owner's adtlress indicated above. Type of ObstruCtions(Describe) � � <br /> Obstructions removed? ❑Yes ❑No Describe <br /> PUMP <br /> Type <br /> 6EOL061CAL AIATERUL COLOR HARDNESS OF FROM TO � Removed ❑�ot Present ❑ Other <br /> FORMATION METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASMIG AND BORE HOIE: <br /> II rqt krqwn,indicate eatimeted formation log from neerby well or boring. <br /> , ��Annular Space Exits <br /> �.� e i <br /> ❑ Annular space grouted with tremie pipe <br /> (�� ❑ Casing Pertoration/Removal <br /> in.from (o tt. ❑ PeAorafed ❑ Ranwred <br /> E <br /> in.from to tt. ❑ �aEad ❑ Remwsd <br /> Type of peAorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Groutlng Matenal �`�� ����r6m � to�L R yards �, ba� <br /> from to H. yards bape <br /> from to R. yards bass <br /> from to_ R. ya� Wps <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on properlyl ❑Yes ❑No Fiow marq/? <br /> UCENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordence with Minnesofa Rules,Chapter 4725. The inlomy0m cawaiisd ii wis�eport is <br /> true to the best of my knowledge. <br /> Don 3todola �Iel,I Dci311ng Co. , Inc. ?.7172 <br /> Contredor Business Name �, % �y. Lir,�snss or Aispis6a%m r'+o. <br /> �...-- i.'1.j'i� �� � � r" '' 1 <br /> AuMonzed Represenfative Signafure Orr <br /> , t. _;�.. ,.�.,_�,��.,� <br /> LOCA�C�'P'Y <br /> H 14 9 7 8 3 Name o/Person See�Yng WeN a Boring <br /> HE-01434-03 �R <br /> r <br />