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Minnesota Well and Boring H 4 9 0 8 4 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealinq No. <br /> �o���y Name WELL AND BORING SEALING RECORD M���esota un�q�e No. <br /> Minnesota Statutes.Chapter 103/ or W-series No. <br /> F��� �Leave blank if nol known� <br /> Township Name Township Na Fange No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br /> �w ��� 23 �� ��,4 � or Boring Constructed <br /> V�V11iJ <br /> Numencal Street Address or Fire Number and Ciry of Well or Bonng Location � i t / <br /> 27V1 �e •�*+�LC LLi.nAl 55331 Depth Before Sealing ��t� fl Original Depth �-�`�1 Fl <br /> Show exacl location of well or bonng Sketch map of well or boring Static Water Level Accurate <br /> in secUon gnd with��X��. locahon,showing property lines. <br /> N i - roads.and buildings. ❑Approximate <br /> i i i i , � <br /> -� -i- -i- -i -:`t . <br /> .,� ` ingle Aquifer ❑Multiaquifer �fl. -� below above land surface <br /> i i i i +V <br /> _i_ _a_ _�_ _i_ CASING TYPE <br /> W i i i i E <br /> � � � � T <br /> -r -�- -r- -r �` <br /> i i i � Steel ❑Plastic ❑Tile ❑Other <br /> mile <br /> _i_ _i_ _i_ _i_ � . J �^_.:`�� , <br /> - � t ���1 � l <br /> S ; Screen from � to fL Open Hole from to ft. <br /> N-i mi�e-� ��-�^------ �3' OBSTRUCTION/DEBRIS/FILL <br /> �� <br /> P OPERTY O N R'S NAME �,Obsiruc[ion ❑Debris ❑Fill' <br /> �eis�c�t �r�isi 471-9001 /� / �f^�f <br /> Type of debris/obsVuction ��J�!'���"�� � ` L/'`�� <br /> Mailing Address d drfferent than property address indicated above. <br /> ObsVuction/Debris/Fill removed? (�Ves ❑No <br /> PUMP <br /> Removed ❑Not Present ❑ Other ����'�7 •'�r'�+ <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depih Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or bonng. � ' <br /> / <br /> � <br /> drift O �in from �to ��.�j ft ❑Yes �lo ❑Yes ❑No ❑Unknown <br /> � in.from to f�. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to R. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �IVo Annular Space Exists <br /> ❑Annular space grouted with iremie pipe <br /> ❑Casing Perforetion/Removal <br /> in.from to fl. ❑Perforated ❑Removed <br /> in.from to tL ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATEiiIAL <br /> �r �,// / <br /> � Groutingmaterial�Aff�f ���from ��o G�G• ft, yards li-? bags <br /> from to fl yards bags <br /> REMARKS,SOURCE Of DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> from to tt. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes o <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance wi�h Minnesota Rules,Chapter 4725.The information contained in this report is <br /> irue to ihe best of my knowledge. <br /> Don Stodola Well Drillir� Co., In�. 27172 <br /> Contractor Business Name . . License or Registration No. <br /> � : <br /> .�,'',,'- /� �� 3-4-�44 <br /> r r <br /> �uth'�presentativeSrgnaTu"re�� Date <br /> ���A����� H 4 9 0 8 4 J�, �t� . <br /> Name ol Person Sealing Well or Boring <br /> � H601434-01 <br />