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�-_..�.,-.� _�-_, - — --�-,-- _ <br /> . � . , <br /> _ � �..� <br /> - > __ °� <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Weli and Boring I �t ?���� � <br /> , Counry Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. I�l -- -- � <br /> ' Hennepin Minnesota Statutes.Chapter 7031 or W-series No. _ — <br /> y (Lseve denk tt rM krawn) <br /> Townshlp Name Township No. Ranqe No Section No. Fradion(sm.-s Ig.) Date Sealed Date Well or Boring Constructetl <br /> Urono 117 23 ' " <br /> � Numencal Street Address or Fire Number and Crty of Well or Bonng Location <br /> Depth Before Sealing �� R. Onginal Depth � „ <br /> ow exact bca ion o v.• or Sketch map of well or bonng ApUIFER(S) STATIC WATER LEVEL <br /> ' m section grid with"X". location, showing property Single Ayuder � MultiaquAer <br /> � lines,roads,and bwldings. <br /> N WELL/BORING Measured ❑ Estimated <br /> �-� �Water Supply Well ❑Monit.Well <br /> •` • � . ❑ Env.Bore Hole ❑Other ��ft. �below ❑ above land surface <br /> W --�- - -- -�-- --i-- E � CASING TYPE�S) <br /> � � � � , <br /> � , . <br /> � � � � � .' <br /> --�- -�-- -i-- --�-- '' ''� �Steel ❑ Plastic �Tile �Other <br /> ylmile <br /> --�- -�-- -,�-- --�-- � CASINCa�S) <br /> Diameter Depih Set in oversize hole? Annular space initia�ly grouted? <br /> S <br /> �i m;�� '� in.from� to�� fl. ❑ Yes �No ❑ Ves ❑ No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to tt. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Properry owner's maiBng aAdress if tliHerent than well locanon address indicated above. in.from to R. ❑ Yes ❑ No ❑ �es ❑No ❑ Unknown <br /> - SCREEWOPEN HOLE <br /> Screen trom 7j to_�.i- ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME � Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> p <br /> Well owners meiling adAress if diflerent Man properry owner's address indiwted above. Type ot ObS��uctions(DesC�ib6) Oda �0[�� <br />� � Obstruclions removed? �Yes ❑ No Describe <br /> i <br /> 1 <br />' PUMP . . .. . . . <br />� TYPQ stroke <br />� � �p <br /> OEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �ry,Removed ❑ Not Present ❑ Other <br />� FORMATION �ry <br /> If not known,indicate estimated formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING ANO BORE HOLE: <br /> � i �No Annular Space Exists <br /> D O �1 ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.irom ro ft. ❑ Pertorated ❑ Removed <br /> in.irom to tt. ❑ PeAorated ❑ Removed <br /> t <br /> Type of pertorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material D�r4.1 �swA from � to_�L_ fl_ yards �_-�1 begs <br /> _ from to ft. yards bags <br /> trom to k. yards bags <br /> . from to__ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DiFflCULT1ES IN SEALING OTHER WELLS AND BORINGS <br /> �� � � � - - .Other unsealed and unused well or boring on property? ❑Yes �]No How many? <br /> UCENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this teport is <br /> �:true to the best of my knowledge. �� �-� � -• <br /> RES J�1,],--Dt,i,l1-i�a�_�a---2�2�6---- <br /> _ Confracror Business Name . Ucense or Reg�istrafion Cio. <br /> �'���' C:� ,��" ,j�-, <br /> . <br /> j��' ,.-. �, .,,,�,.-�:-. ' <br /> Authonzed Representative Signature Date <br /> -- - -_ <br /> Bob 6-1�-01 <br /> LOGAL COFY H ���[f�� Name ol Person Sealing Well or Bonng <br /> �� <br />