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MINNESOTA DEPARTMENT OF HEALTH Mmnesota Well and Bonng `— � , <br /> WE��oRBop�N���AT�oN WELL AND BORING SEALING RECORD SealingNo �H 141701 <br /> Counry Name — <br /> Mmnesola Urnque No. <br /> Mmnesota Statutes,Chapte�1031 or W-senes fvo. <br /> 21112e #.22 ILeave Wank d rw�known� <br /> Township Name Townshlp No. Range No Section No. Fractlon�sm.-i Ig.) Date Sealed Date Well a Bonng CaWn,ctea <br /> ,�To 118 21 30 "11�`���}. �1 Z 9/99 2�A <br /> Numencal Street Adtlress or Fire Number and Ciry ol Well or Bonng Location <br /> 85 Stubbs Ba Ro�d, La�.e *Qt 55356 Depth Before Seahng 13� fl Origlnal Dep�h h <br /> Show exad location of well or boring Sketch map of well or bonng ApUIFER�S) STATIC WATER LEVEL <br /> in sectron gnd wrth'X'. - bcation, showing p�operty Single Aywfer ❑ MulUaqwfer <br /> Gnes,roads,and buildmgs. <br /> N WELL/BORING �Measured ❑ Est�mated <br /> Water Supply Well ❑Monit Well <br /> ❑ Env.Bore Hole ❑Other _ Q�} ry. �pelpw ❑appre land wAace <br /> W --'"- - -- - -- --'-- E CASING TYPE(S) <br /> -i-- ---- -i-- --�-- � Steel � Plastic �Tile �Other <br /> F mile <br /> --`- -�-- -�-- --i-- � CASING <br /> Diameter DepM Set m overs1ze hole? �yy�„rpary ywled7 <br /> �t�—�►e `� in.from � to Z 3� ft. ❑Yes �d-1 No ❑Yes ❑No �]UNuwwn <br /> I 1` �` <br /> PROPERTV OWNER'S NAME in.irom to fl. ❑Yes ❑No ❑res ❑No ❑UNvn�^ <br /> P <br /> Pp�qrb ownefs maihrg address if tllflerent than well iocation address indicated above. in.from to ft. ❑ Yes ❑� ❑r� ❑� ❑�Q� <br /> Y O.� <br /> k85 Stubbs 8831 �c�.F2 SCREEWOPEN HOLE <br /> lLBng L�ke, MPT 55356 Screenirom 1�� to z3� n o��f,aer.� b R. <br /> OBSTRUC710NS <br /> WELL OWNER'S NAME Rods/Dro Pi �No ObunxUon <br /> ❑ p pe ❑Chedc VaNe(s) ❑Debris ❑Fill <br /> Well ownefs meiNrg address if ditterent than property owner s address indicated above. Type of Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑No Describe <br /> PUMP <br /> Type <br /> (iEOLO(i1CAL AIATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Otlier <br /> fORMATION <br /> H rat kravm,kidicate eatimated tormatbn log trom nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASp1GS,OR CASN('A!b BORE HOLE: <br /> 'Q,,L�, No Annular Space Exits <br /> LJ Annular space grouted with tremie qpe <br /> ❑ Casing PeRoratioNRertaval <br /> in.from to 1t. � PaAara�ed ❑ Fian�wad <br /> in.from to R. ❑ PaAoralsd ❑ Ranwred <br /> Type of peAwata <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material ���'t fiw�t, r,a,,, 4 � 130 � � 21 � <br /> rrom ro R yards tnps <br /> hom 10 R pbs bqs <br /> from to R Ya�ds ��ps <br /> RENARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boreg m property? ❑Yes No Fio�r marq/? <br /> UCENSEO OH REGISTERED CONTAACTOR CERTIFICATION <br /> This well or boring was sealed in acoordence with Minnesota RWes.Chaplx 4725. The iromqYon caMrrd i�hs�aport's <br /> true to the best of my knowbdpe. <br /> �����'��� <br /> Sreve*�s T►ril_?i;�� & E:av. Servlces 866�4 <br /> ��� � � 57�J Conhador Business Name (i�rw or Repsla�on Ria <br /> Q� <br /> -- 2l1199 <br /> i:.,;' - " �.i"'.�i i;�: Autlwrized RepresenfatiNe S1gneNie Orb <br /> Richard Steve:a� <br /> LOCAL COPY H ! ����� Neme ol Person SealinD WeN or Bonrg <br /> 1 <br /> HE-01�3/-03 2�J7 R <br />