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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12 6 514 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. <br /> Councy Name Minnesota Unique No. <br /> F..ennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Townshi No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> orano li�i 23 i7 2;no�7 ,, 2� J� � <br /> N{��jri Street Address or Fire Number and Ci of ell or nBoring Location � � <br /> 1!� Fa;erness P� ��� VrfllfO Depth Before Sealing l� � ft. Original Depth � � � ft. <br /> Show exact location of well or boring Sketch map of well or boring UIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". ,t location, showing property Single Aquifer ❑ Multiaquifer <br /> � w�� lines,roads,and buildings. <br /> N _�..----- WELUBORING �Measured ❑ Estimated <br /> � � � Water Supply Well ❑Monit.Well , <br /> - -;-- --;-- �!�' <br /> � ❑ Env.Bore Hole ❑Other 7 -' ft. �below ❑ above land surface <br /> __f_ _l__ _l__ __l__ 4..__f_ <br /> yy E � CASING TYPE(S) <br /> � � � � <br /> � � __�_,._, <br /> � � � � __—'-- <br /> --�- -�-' "�-- --�-- �Steel ❑ Plastic ❑Tile ❑ Other <br /> ;c mi�e <br /> --�- -�-- -�-- --�-- � - CASING <br /> � � � � ,�+. `�^� ���` Diam tef� Depth . � Set in oversize hole? Annualar space initially grouted? <br /> l� S """��,��� ___- <br /> µ—i m��e--qe . in.from � to f� -' ft. ❑ Yes �Alo ❑Yes ❑No ❑ Unknown <br /> I I <br /> P�O�nO NER'S NAME � in.irom to tt. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> �e�son G71-o3s1 <br /> PropeAy owner's mailing address if ditterent than well location address indicated above. in.from to ft. ❑Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> $t tn:.Tenny Hewson SCREEWOPEN HOLE <br /> � , <br /> Screen from �4-` to L',�� ft. Open Hole from to ri. <br /> file�971G�431 <br /> OBSTRUCTIO WDEBRIS/FILL <br /> WELL OWNER'S NAME �Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owners mailing address if tliHerent than property owner's address indicated above. Type of Obstruction/Debns/Fill _.�NNf�l / -=�/""�'� `�` 1` Ur�� <br /> Obstruction/Debris/Fill removed?�Yes ❑ No <br /> PUMP <br /> �y�� 'c`j L�� ��1,������ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated fortnation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> r <br /> %Lf-,J i.!r�/f��.t.� <br /> Grouting Matena�� from � to /� ft. yards / � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes �No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation contained in this report is <br /> true to the best of my knowledge. <br /> Don Stodola W�11 Dril2ingCo., Inc. 27272 <br /> Conhaclor Business Name � License or Registration No. <br /> ✓ � ''� <br /> �.. ,� � �� <br /> �i'���'1 I <br /> Autho zed epresentative Signature - Date <br /> Jim Antonson <br /> LOCAL COPY H 12 6 514 Name ol Person Sealing Well or Bonng <br /> HE-01434-02 10/95R <br />