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MINNESOTA DEPARTMENT OF HEA�TH M�nnesota Well and Boring � � •, <br /> WELL OR BORING LOCATION Sealing No �"� �4,���s <br /> County Name WELL AND BORING SEALING RECORD Mmneso'a Urnque No. -- <br /> �@L�nE�Iil Mmnesota Statutes,Chapter 1031 or W-ser�es No. J I_� <br /> ILeave blank il np�known) <br /> Township Name Township No. Range No. Section No. FracOon(sm.-►Ig.) Date Sealed Date Well or Bormg ConsVuded <br /> cJrono 117 23 Q7 14—d415 3c3 El�'i�'-�- ^� <br /> Numerical Street Adtlress or Flre Number and Gry of Well or Bonng l.ocanon �f <br /> 1y�*Linden Lane, ��0�� 553b4 DepthBeforeSeahng ff� , R OngmaiDepih C/� t n <br /> Show exact location of w�ell oi bonng Sketch map of well o�onng UIFER(S) STATIC WATER LEVEL <br /> in section grid with`X'. locahon, showing p perty Single Aywfer ❑ Multiaquder <br /> lines,�oads,and buii ngs. <br /> N WELUBORING Measured ❑ Estimated . . <br /> � � � � .� ~��--,_ Water SupD�Y Well ❑Monit.Well r <br /> � � � � �. �..� <br /> -r' -T- '�- -'r- �� . ����. �/ . <br /> � � � � <br /> `{�� ❑ Env.Bore Hole ❑Other _ ����-y R. [[a�below ❑ above land suAace <br /> � � � � �' - <br /> W -�- -i-- -i- -- -- E ... Q CASING TYPE(S) <br /> � � � <br /> � <br /> , � � � <br /> -�-- -;-- -i-- ---{-- � Steel ❑ Plastic �Tile � Other <br /> u mde <br /> � � � � � CASING <br /> -�- -�-- -�-- --1-- <br /> Diameter' Depth t�� � Set in oversize hole7 Annualar space initially grouted? <br /> S �{ <br /> ��,��� � , in.from� to R. ❑ Yes ��No ❑ Ves ❑No ❑ Unknown <br /> P P TY O ER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> �y�e �as�erik 472-4846 <br /> Properry owner's maiGng address if tllflerent than well location atldress indicated above. in.from to ft. ❑ Yes ❑ No ❑ Ves ❑No ❑ Unknown <br /> SCREEWOPEN HOLE� <br /> 1�V / Linden Laz�e Screenfrom�to � �� ' fl OpenHolefrom to ft. <br /> �Y. oesTaucnoNs <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑/ Fill ❑ No Obstruction <br /> Well owners mailing address it ditlerent Man properry owner's atltlress mdicated above. Typ6 ot ObSl�udions(DeSC�ibe) `���'�t�` • -^�� � �`• Yf _ <br /> Obstruclions removed? �'es ❑ No Describe <br /> PUMP <br /> Type <br /> OEOLOOICAL MATERIAL COLOH HARDNESS OF FROM TO � Removed �] Not Piesent ❑ Other <br /> FORMATION - <br /> It rat krawn,indicate es�imated fortnatbn log from nearby wel�or bonng. M�EyT�,HOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> AJ No Annular Space Exists <br /> ❑ Annular space grouted with tremie pipe <br /> �� Casing Perforation/Removal <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> in.irom to fl. ❑ Pertoreted ❑ Removed <br /> Type of perforalor <br /> ❑ omer <br /> CaROUTING MATERIAL(S) <br /> f, i <br /> Grouting Material N�f��f ��i/,�,�FOm Q to ��� it. � <br /> yards bags <br /> from to ft. yards bags <br /> from to ft. yerds begs <br /> from to-- R. yards begs <br /> REMARKS,SOURCE OF DATA,DIFFICUlT1ES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The infortnation coMained in this repoA is <br /> true to the best of my knowledge. <br /> Don Stodo2a Well Dcillf.n Co. , Inc. 27172 <br /> Contrector Business Name License a Registretion fio. <br /> " / �f' � f' ���. <br /> j r,✓�( <br /> ori R resentative Signatiira'"" Oete <br /> � m '�n�'c�r�saY, � - �-�q <br /> Name o Person Sealing Well or Bonng � <br /> LOG1L COPY H <br /> HE-01434-04 8�98 R <br />