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1 <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and eoring ��5 3 2 5 I <br /> WELL OR BORING LOCATION Sealing No. H i <br /> ����N�,B WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or�W�p e�s N�o. <br /> � <br /> Township Name Townshlp No. Range No.Sectlon No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> OrQ�O k k k � /� / <br /> V <br /> GPS ��de degrees_ minutes_ seconds Depth Before Sealin �� 8. Original Depth R � <br /> LQCATION: Longitude_ degrees minutes_ seconds ��R�S) STATIC WATER LEVEL <br /> Numarical Street Address or Flre Number and City of WeII or�ring Locatlon ingle Aqu'rfer ❑MulUaquffer �+ <br /> WEJ'L/BORING Measured ❑Estlmated Date Measured✓ `� <br /> 12�5 ArTmr St (�no 55391 ;�Water-Suppiy Well ❑Monft.Well /�./� � ,y <br /> Show enact locadon of well or boring Sketch map of well or ring ��gore Hole ❑Other _�fL l�below ❑above land surface <br /> in section grid with°X." loca8on,showing pro • � <br /> N Iines,roa\`d buitdi CASINO TYPE(S) <br /> --'-----'-----`-----`-- �/ <br /> ���- s��i ❑Pi�uo ❑r�ia ❑ou,e� <br /> ; ; ; ; <br /> --i------'r-----l-----�-- WELLHEAD COMPLETION <br /> W__�_____Y_____�,_____�__ E T u[side ell House At Grade I�Id ment Ottset <br /> O : ❑W ❑ e:� <br /> 'h Mne �� ❑pitiess qdapterNnk ❑Buried ❑Well Ptt <br /> --:-----T----�-----:- 1 <br /> - ❑s�hau ; <br /> ' ' S ' ' `�Well PR � <br /> ❑other <br /> �1 Mile� ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASINO(S) � <br /> Ci t?� 4L'C�ilO o��eca�� � Depth � Set in oversize hale7 Mnuler space fnitlally grouted? � <br /> Property owneYs malAng addreas M dlHererrt then well ta�tlon addreas indicated above �_in.from � to�R ❑Yes �No ❑Yes ❑NO ❑UnlmoWn <br /> P�O� ��q � in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unlmown I <br /> C�T.Stix.! B�' �?�T 5���� <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unlmown I <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE , <br /> I <br /> Well ownePs malling address H ditferent than properry ownets address IrMicat�above ��n ftom�to r s� ft. Open Hote from to ft. <br /> OBSTHUCTIONS i <br /> �tods/Drop Pipe ❑Check Valve(s) ❑Debris ❑FII ❑No Obstruction <br /> Type of ObsVuctions(Describe) NAw� /�.�{"T �' ����LI—� l <br /> GEOLOGICAL MATERIAL COLOR �DNEss oR �OM � Obstructions removed7 Yes ❑No Describe <br /> FORnoanoN <br /> If not known,indirate estimated tormadon log from nearby well or boring. P�MP � <br /> . � T,� �7'IR01� �ut1n&� <br /> � �Flemoved ❑Not Present ❑Other <br /> ME�HOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: i <br /> No Mnular Space Exists ❑Mnular Space Grouted with Tremle Pipe ❑Casing PertoratloNRemoval <br /> in.from to ft. ❑PerForated ❑Removed ' <br /> in.from to ft. ❑Perforated ❑Removed <br /> I <br /> Type of Perforetor ! <br /> ❑other <br /> aROUTING MATERIAL(S) (Orre bag of cemeM=94 Ibs.,orre bag of berrtonile=501bs.) <br /> w �.�,,� f '�j!� <br /> Grouting Material/vL�/ C:G...��lfrom � to}�(t. yards�bags II <br /> from to ft. yards bags ', <br /> from to ft. yards bags '' <br /> OTHER WELLS AND BORINGS i <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or bodng on property7 ❑Yes o How many7 I <br /> LICENSED OH REGISTERED CONTHACTOR CERTIFlCATION � <br /> � This well or boring was sealed in axordance w(th Minnesota Rules,Chapter 4725.The informaUon contained in this report <br /> is true to the best of my Imowladge. <br /> l�0il Sfi0a.0�8 �1.Z j?l�. CO. IIIC. <br /> Licensee Busfness N License or Regishadon No. <br /> /�'i-a-G7 <br /> � Ce e epreserrtaWe Sign Certifled Rep.No. Date <br /> �ANT-FILE WITH PROPERTY ��5 3 2 5 Name of Person Sealirtg Well or Bodng I <br /> •WELL OWNER COPY H <br /> IC#140-0423 5l07R <br />