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wELL OR BORING LOCA7iON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i ���A�A � <br /> Counry Name WELL AND BORING SEALING RECORD Sealing No. �H 3_3 <br /> Minnesota Unique Well No. <br /> g�IIn`y��� Minnesota Statutes,Chapter 103/ or W-series No. <br /> (Leeve Harik M not krqwn) — _—— ____ � <br /> Township Name Township No. Range No. Section No. Fracuon�sm.-►Ig) Date Sealed Date Well or Boring Constructed <br /> 3 <br /> Qt!?1!#} 1}.7 23 (3it 3�#-t�t?]. g tX� OO <br /> Numeqncnal Street Adtlress or Fire Number and Gry of W/r�ell or Bonng LocaCuon g/� r � <br /> I.7 V� Shnre�i°i�iis �r s 1t,�Q�� J�J 3 Depth Before Sealing iQ J ft Original Depth �V� h <br /> Show exact locah o el o o i Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property Single Ayuiter � Multiaquder <br /> Nnes,-roads. buildings. <br /> 1 <br /> N ��.u`r-.s.,a.,�-.,_,_,..,. �,h , WELUBORING �Measured ❑ Estimated <br /> Water Supply Well ❑MonN.Well / � <br /> --------{ ❑ Em.Bore Hole ❑Other i� R `�elow ❑ above land surtace <br /> W -- - - -- -�-- --'-- E l� CASING TVPE(S� <br /> � ; � <br /> � � � <br /> � � � � <br /> --�� ��-- -�-- �-�-- � �Steel ❑ Plastic �Tile � Other <br /> jzmile <br /> -�-- -�-- -�-- --i-- � CASING(S) <br /> Diameter Depth � Set in oversize hole7 Annular space initially grouted7 <br /> �r mi�e—qr �'r in.irom� b� ft. ❑Yes �lo ❑ �es ❑No ❑ Unknown <br /> i <br />�. � PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> Property owner's mailmg address il difler t an well location atldress indicated above. in.from to ft. ❑ Ye5 ❑ No ❑ �es ❑ No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> / � <br /> Screen from�to ft3� ft. Open Hole irom to R. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME � �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �o Obstruction <br /> �„ <br /> Well owner's meiling address it dilferent than property owner's atltlress indicated above. Type of Obstructions(Describe) � � � � <br /> _ �— <br /> Obstruclions removed? es ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLO(iICAL MATERIAL COLOR HARDNESS OF FROM 70 � Removed Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimateA formation log from nearby 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.trom to tt. ❑ Perfaated ❑ Removed <br /> in.from �o R. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> �9 / <br /> ��� Grouting Ma�enal /��q���J�rom .�_ to�� tt. yards � bags <br /> from to R. yards bags <br /> t` <br /> � from ro ft. yards begs <br /> from to—_ ri. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes � No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this repoA is <br /> true to t�e best of my knowledge. <br /> llon Stadcla �ell D�rilliQg Co. , Inc. 27I72 <br /> Contracror Business Name License or Registrefion Yvo. <br /> :_�,___. .. - <br /> .. ,,' _ ,,.J f�. <br /> _'- � - <br /> o sen tive Signefure Dafe <br /> � --- , <br /> y "�.,.�..����,� q-�.� <br /> �t�r-�s '� �w H ���3�3 Name ol Personr ing Well or Bonng <br />