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_ _._-1 ,_,,��- � : �. � . ���-:T <br /> • �- . �. .�� : � <br /> ,, . _. _ ; . ���.��vk . � ^` ...���_._ � :�. <br /> MINNESOTA DEPARTMENT OF HEALTH M�nnesota Well and Bonng � —� 'i <br /> WELL OR BORiNG LOCATION Sealing No !H 1,�.���� <br /> Counry Name WELL AND BORING SEALING RECORD M,��eso:a„�,q�e No — <br /> H�nn��rin Mmnesota Sta�utes,Chapter 1031 or W-series No � <br /> 1Leave Dlank�I n�1 known� <br /> Township Name Townshlp No. Range No. Section No. Fraction(sm.i Ig.) Date Sealed Date Well or Bonng ConslructeA <br /> Urono li7 23 21 , N 9/17/�$ <br /> Numencal Street AdAress or Fire 1Number and City of Well or Boring Locanon ,] �y <br /> Z 6.�� �G�pIQ �l d�� �d�� Depth Be�ore Sealmg l��7 fl. Oriqmal Depth l��3 fl. <br /> Show exact loca6on ol N•ell or boring Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL <br /> in section gnd with'X'. � i A'�. bcahon, showing propeny �Single Ayuder ❑ Muluaquifer <br /> � ~ lines,roads.and bwldings. <br /> N WELUBORING Measured ❑ EsGmatea <br /> � � � ...w` hi <br /> [�.Water Supply Well ❑Monit.Well <br /> - - -T- -;-- --'-- y^��, t��tr �� ❑ Env.Bore Hole ❑Other _ �� h. �]��pN, ❑app�e Wnd suAace <br /> W -- - -'r- -i-- --i-- E Ic,�. .,.�"_.� CASING TVPE(S) <br /> � ��� <br /> —�- ---- -i-- -�— � �".Steel ❑ Plastic ❑Tile ❑Other <br /> %mde <br /> __�_ � CASING <br /> -�-- -i-- -i-- <br /> Diameter Depih Set m oversize hdeT qnnualar space inrtiaNy grouled7 <br /> S !� ^y �[ <br /> L�i,,,,y� � in.from V to ��` ft. ❑ Yes [yNo ❑Ves ❑No ❑ UMvawn <br /> f <br /> PROPERTV OWNER'S NAM in.from to ft. ❑ Yes ❑No ❑Yes ❑►� ❑�^w�� <br /> Property ownefs mailmg adtlress if diflerent than well IocaUon address�ndicated above. in.from to R. ❑ Yes ❑No ❑Y� ❑� ❑U��� <br /> SCREEWOPEN HOLE <br /> Screen irom to k. Open Hole from�to� k. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME <br /> [$Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑No ObstnkGon <br /> Well owner's meilirg aAtlresa N diflerent�han property owner's atltlress indicated above. Type of Obslructions(DesCribe) 'y1�1$��j �i�� i�nLt �3.r� <br /> Obstructions removed? $�Yes ❑ No Describe <br /> PUMP <br /> Type b1113�1�Y'.^a��71� <br /> (iEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Otlier <br /> FORMATION <br /> tl nM Wiowm,intlicate esumeted fameGon bg from nearby wel�or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASINC AND BORE HOLE: <br /> �.No Annular Space Exits <br /> � ❑ Annular space grouted with tremie pipe <br /> r�-L•K 2 8'7 �� ❑ Casing Pertoration/Removal <br /> in.from to R. ❑ ��ed ❑ Hamoved <br /> in.trom to R. ❑ PeAorated ❑ Rart�orsd <br /> Type of perforala <br /> ❑ omer <br /> GROUTING MATERUL(S) <br /> Groutlng Material �Qr�r.2 a n� from �..st5,� to�� rt. yards L r1 bags <br /> , from to R. yards b� <br /> r�om co n. raras e.45 <br /> hom to__ fl. yards b�ps <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEAIING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes ;�No How marry/? <br /> LICENSED OR REGISTERED CONTRACTOR CERTFICATION <br /> -� This well or boring was sealed in accordence with Minnesofa Rules,Chapter�725_ The�fonnatio�cantained'n tltia�aport is <br /> true to Me best of my knowledge. <br /> �LS i�all Drilliu� 27276 <br /> Contraaor eusiness Wame Licarrss o. r.o. <br /> .a=' � f^ , <br /> % , ,.� /S_� `��� <br /> Autho ed Represenfafive Si�eNie Deb <br /> �3ames LZa3. <br /> LOCA! !'OPY H 1416 6 9 Name ol Person Seelinp WeM a Boring <br /> HE-01430-03 2197 R <br />