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WELL OR BORING LOCATION <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12 7 9� 4 <br /> County Name WELL AND BORING SEALING RECORD Sealing No. <br /> �1L�IIT1� 71I1 Minnesota Unique No. <br /> r Minnesota Stafutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-►Ig.) Date Sealed Date Well or Boring Constructed <br /> G�-c�r��� 117 �3 C;6 � v � �-� :�._: f_ <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location � � <br /> `�1(' MC'��1 i �.�1 ��1.Ve drE.1IlC.:� �i�i. � ' �efore Sealing J�� ft. Original Depth ��� fl. <br /> Show exact location of well or boring - oring ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing pr�perty Single Aquifer ❑ MWtiaquifer <br /> lines,roads,and build' gs. <br /> N WELUBORING �Measured ❑ Estimated <br /> � � �Water Supply Well ❑Monit Well � <br /> _T_ _ _ __ __ __l__ _.�..�.�..�_�.�.�._..��..,� ' <br /> ❑ Env.Bore Hole ❑Other t"-l.` ft. �below ❑ aboveland surface <br /> W --�- -�-- -i— --i-- E ._.___ CASING TVPE(S) <br /> _ . <br /> -Y- -�-- -'�-- --�-- � � ��� �Steel ❑ Plastic ❑Tile �Other <br /> W mile <br /> -�- -.�-- -�-- --i-- � CASING <br /> Diamet�� Depth � Set in oversize hole? qnnualar space initially grouted? <br /> S ",� / P"� /� / <br /> �r miie—�x �tf '�_.+,✓��'�-�- t-�-.1.� . � in.from s,,.�_ ro I�5�1. tt. ❑ Yes �No ❑ Yes ❑No ❑ Unknown <br /> I <br /> PROPERTYOWNER'SNAME Gh�3.r1ES CuCY�! �Q. in.from to tt. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> Properry owner's mailing address if diNerent than well location address indicated above. in.from to ft. ❑Yes ❑ No ❑ Yes �No ❑ Unknown <br /> �p l�L �MC?L.iC�Clcl�E� D.r].V E' SCREEWOPEN HOLE <br /> W��c3bury Mr�. �_>1 �_> • � <br /> /���J 1 J,'r Screen from ��� to j?'� ft. Open Hole from to R. <br /> OBSTRUCTIO WDEBRIS/FILL <br /> WELL OWNER'S NAME �Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if diHerent than property owners address indicated above. Type of ObstructioNDebns/Fill �d!/i�f //��'�'� �" v �>>!�s/� <br /> Obstruction/Debris/Fill removed? f�Yes ❑ No <br /> PUMP <br /> Type ��'d� �'G�/��� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> fORMATION <br /> If not known,indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE: <br /> j " �No Annular Space Exits <br /> �'�.. �>. <br /> ❑ Annular space grouted with tremie pipe <br /> I,i ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of peAorator <br /> ❑ Other <br /> GROUTING MATERIA�(S) <br /> / <br /> Groutin Matenal d,�.��/'� �'�✓�r.�� rom � t � <br /> g , � _i� to�` fl. 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 /> ..,e,�:`_. . true to the best ot my knowledge. <br /> DON ;.�:'�DOLF� t�ELL DRILLING CU. , IIVC. ?..71 ;< <br /> ' � � `sy; <br /> Contrector Business Name License or Registrallon No. <br /> � � _ F 'y ��' ,�-� J! / � <br /> ut ed epresentative Signafure � Date <br /> `�tr�..;.� �t.�„_,� v-� <br /> LOCAL COPY H 12 7 9 � 4 Name o/Person Se qg Well or Bonng <br /> HE-01434-02 10KJ5R <br />