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,._...,.� ..�T._.� ,..T�. . , �.__TT .�.� ,� . �. _ T. _ �._ �.,. , _.. ._ 1 <br /> , _ + . , <br /> � • <br /> MINNESOTA DEPARTMENT OF HF_ALTH Minnesota Well and Boring ��a A�f� � <br /> WEIL OR BORING LOCATION I <br /> County Name — WELL AND BORING SEALING RECORD M;��'e90 a u��q�e we��No. !H— r,�j}- � <br /> Minnesota Statutes.Chapter 1031 or W-series Na � � <br /> ti.ev.dar�x n nm knownl . <br /> Township Name �Township No. Fange No. Sechon No. Fracuon�sm.�Ig.) Date Sealed Date Well or Bonng Constructed <br /> �tOAt� Z�7 �� �� ��.'{��� 2 <br /> Numencal Street Address or Fi�e Number and Ciry of Well or Boring LocaUon /y,��S � /��// / <br /> 3245 Car��� �� V� �� Depih Bebre Seahng ` V�� N Original Depth _ ��L_n <br /> Show exact location of well or bonng Sketch map ol weil or bonnq ApUIFER(S) STATIC WATER LEVEL <br /> in section gnd wRh"X". locauon, showing property Single Aywfer ❑ Mul6aqwfer <br /> lines,roads,and buildings. <br /> N WELUBORING Measuied ❑ Estimated <br /> ;. �- Water Supply Well ❑Moni�.Well �"//� � <br /> j I , -I-_ � ❑ Em.Bore Hole ❑Other !L,L_ft. �below ❑ above land surtace <br /> W --�' '�'" -�'- - E CASING TYPE(S) <br /> , <br /> � i � � ....k,.....-f.< <br /> ---- -�- -i— --�— � �'-� � Steel � Plastic �Tile �Other <br /> { <br /> � � }�imila �.- �t� <br /> ____ '�" '�" __�__ � ,,��. CASING(S) <br /> � Diameter Depth � Set in oversrze hole? Annular space initially grouted? <br /> �i mne—q. �,.� _L1— in.irom� to��ft. ❑ Yes �No ❑ Yes ❑No ❑ Unknown <br /> i <br /> PROPERTV OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ Ves ❑No ❑ Unknown <br /> .� <br /> PropeAy owner's mailing adtlress�f i erent than well iocation address indicated above. in.trom to fl. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> f �}� /`/ <br /> Screen from ` � �`�' ro I$7 ft. Open Hole from to R. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Dro Pi e <br /> p p ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owneYs mailing address if diHerent than properry owner's address indirated above. Type of Obstruclions(Describe) ��w�� f.Ja�= �" �C� <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP <br /> Type <br /> 6EOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> • �lo Annular Space 6cists <br /> �.w fY� <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforallon/Removal <br /> in.from to tt. ❑ PeAorated ❑ Removed <br /> in.irom to ft. ❑ PeRorated ❑ Removed <br /> ' <br /> Type of perforator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs„�one bag of bentonite=50 Ibs.) <br /> Grouting Matenal �E�F ��/�+�`^'�from '+� �to�k. yards � bags <br /> from to R. yards bags <br /> from to ft. yerds bags <br /> from to__ ft. 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 /> LICENSEO OR REGISTERED CONTRACTOR CERTiFICATION <br /> This well or boring was sealed in accordance wiM Minnesota Aules,Chapter 4725. The information co�tained in this report is <br /> true to the best ot my knowledge. <br /> �n Sied+al.a iiellDrillittg �s�. , Inc. 27172 <br /> Contractor Business Name � License a Registretion Yvo. <br /> �_- <br /> ��`J - �� �.✓��.! <br /> � � <br /> p senfa rve Si nefure '- Dafe <br /> r,., { ��j <br /> ^���! .7'"'r"Y."" ��.✓ '"-.J'v^"`�"e'/'y'4`"'�`�"_' <br /> u ������ Name ol Person ny Well or Bonng <br /> f7 <br />