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MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ������ � <br /> WE��op Bop�N��o�AT�oN — WELL AND BORING SEALING RECORD sea''"9"°. �H <br /> County Name Minnesota Unique Well No. I --- <br /> Mmneso�a Statutes.Chapter 1031 or W-series No. � _ � <br /> r�el9�l��J�i3 �.�.w�n�ak�� <br /> Township Name Township No. Fiange No Secaon No. Fracuon�sm.-i Ig� Oate Sealed Date Well or Bonrg ConsTructea <br /> f_}[Oflb 1�� �� �� c�ir�"Q'T3�'. - �� -,� = <br /> Numencal Street Address or Flre Numbe�and Gty of Well or Boring Location _ , <br /> /1n � ` <br /> 7�z� ��J£')�QD(��i �j�j�� �/�Q['!Q �5�'9 2 Depth Bebre Sealing � n Origmal Depth _�"7(' tt <br /> Show exact locahon ol v,�ell or boring Sketch map of well or�oring. AOUIFER(S) STATIC WATER LEVEL <br /> in section grid wdh"X" bcation, showmg pr perty Sing�e Aywfer f] Mulhaquder <br /> Gnes,roads,and bwldings <br /> N , v � WELUBORING Measured ❑ Estimatetl <br /> � � ; � . � [�Water Supply Well ❑Monrt.Well <br /> j � � ; � Q1Env Bore Hole ❑Olher _._ �_ft �below ❑ above land surtace <br /> � � � � . � <br /> W --�- -=-- -=-- --=-- E ' � � � CASING TYPE(S) <br /> � � <br /> � � � i • <br /> � { , � <br /> � � � - f . <br /> ' ' � .J �Steel � PlasUc �Tile � Other <br /> _�_ _�__ _�__ __�__ . <br /> ylmile -._____."-_ . . — <br /> -�-- -=-- -�-- --�— I i CASING(S) <br /> � �� ~ Diameter Depih J Set in overs¢e hole� Mnular space initially grouted7 <br /> LL�� S __ - ,- ,, /l � l�' <br /> y�r mrre� - in.from� �o ft. ❑ Yes No ❑ �es ❑No ❑ Unknown <br /> I <br /> i <br /> PROPERTV OWNER'S NAME in.from ro tt. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> �'+ . !- .. <br /> Property owner' aifing ad ress i Ai erent than wel locanon address indicated above in.from to ft. ❑ Ves ❑ No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> � 1 <br /> Screen irom to R. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME [��Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> T <br /> Well owner's maili address if diflerent than r e owner's address indicated above. `° �� �r?�'�� '-1 f�' '�"t��` <br /> ng p op rty Type of Obstructions(Describe) , <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP <br /> Type l�`---�.. � !:i"�t' <br /> GEOIOGICAL MATERIAL COLOR HARDNESS OF FROM TO qt.Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> � If not known,irWicate esBmated formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE: <br /> ; , �lo Annular Space Exists <br /> - _.. � ���: �` <br /> � - ' .. ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to k. ❑ Pertoraled ❑ Removed <br /> in.irom �o ft. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> ,-, , Y_ --.-y.. %i: <br /> Grouting Material f'��� �-' ' "`� � �'-�rom i:% to �T tt. yards _,. bags <br /> trom to h. yards bags <br /> from to fl. yards begs <br /> from to_— fl. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOH CERTIFICATION <br /> - This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best ot my knowledge. <br /> ['��r� �'t�r�c,l� rdell �1r�llir��; ca. , Ir,c, 27172 <br /> Confractor Business Name .. License or Registration Yvo. <br /> � ,: , <br /> � / <br /> _, . /� .//,. /,f � J�,?`� '`! .. _- !., ,�`��-.�" i / '.i + <br /> ;`..� ��� 1 r,�. � .��-� <br /> �gr'ed Re¢rese�e Signature Defe <br /> _„-�.." <br /> . . ... . ,j�.i-:�- �.i�.�..-�'" ..-..i'' <br /> J ^���� Name ol Persar Sealing Well or Bonng�� �. <br /> LOCAL COPY H „1.J <br />