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� _ � <br /> �� �j �����:�C�' /�G�'�- � X <br /> �-,l�/�A"A\ ,�'fl�� <br /> V- MINNESOT EPARTMENT OF HFALTH Minnesota Well and Boring <br /> WELL OR BORING LOCATION �yELL A ORING SEALING RECORD Sealing No. �H �,���6�„ � <br /> Counry Name Minnesota Unique Well No. I -- <br /> �QnQp�� Minnesota Statutes,Chapter 1031 or W-series Na � � <br /> (L�ev�deM rc na knvxn) <br /> Township Name Township No. nge No. S ion No. Faction�sm.-i Ig� Date Se ate�Well or Bonng Constructed <br /> `` 7 21 3��(3�2 �-. <br /> 2.� f� 0 4 <br /> �yu/e/�nc/a�l ireet Atldress o�Fi N er nd tv of Well or Bonng-Location 1 ' -7'` r <br /> G S,�Ctl,� ��Q$$$n fiLl� ����� �`�,�j��� oth Before Sealing ��`` ft. Original Depth . `-v i� n. <br /> Show exact Iceation of well or borin Sketch map of well or bonng AQUIFER(S) STATIC WATER LEVEL <br /> i locahon, sAo ing property Single Ayuder � Multiaquifer <br /> i lin roa s,� d buildin s �/ <br /> ry '`�,`-����-+>>r"y--�-"��� �� �`�-� 9 WELL/BORING J�J`Measured ❑ Estimated <br /> Water Supply Well ❑Monit.Well /-� � <br /> ❑ Env Bore Hole ❑Other _ �R. �below ❑above land surtace <br /> W --�" '�-- -�-- --'-- E CASING TYPE�S) <br /> � � � ��� � <br /> � � � <br /> -�-- -;-- -r- --;— � i � �Steel � Plastic �Tile � Other <br /> � � � � Y�mile -�j- � <br /> -�-- -i— -�-- --1-- � � CASING(S) <br /> Dlameter Depth � Set in oversize hole7 Annular space initiaily grouted? <br /> S ��_.1-•-�----s.-.� `,,,) /, � � 1� <br /> ��m�� in.from to R. ❑ Yes o ❑ �es ❑No ❑ Unknown <br /> PROPERTV OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Properry owne�s mai ing address if dAferent than well IocaBon address intlicated above. in.from to R. ❑ Yes ❑No ❑ Yes ❑No n <br /> .�S�IEa$S SbOV� SCREEWOPENHOLE r ` <br /> Screen from � ro� ft. Open Hole from to k. <br /> OBSTRUCTIONS <br /> WELI OWNER'S NAME ❑ Rods/Dro Pi <br /> p pe ❑ Check Valve(s) ❑ Debris ❑ Fill No Obstruction <br /> Well owners mailing address if diMerent than property owner's address indicated above. Type ot Obstructions(DesCribB) <br /> Obstruclions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> OEOLO(i1CAL MATERIAL COLOR MARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> N rat krawn,indicate estimeted fortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists <br /> d ❑Annular space grouted with tremie pipe <br /> ❑Casing PerforaHon/Removal <br /> in.f�om to R. ❑ Perforated ❑ Rertroved <br /> in.irom to n. ❑ PeAorated ❑ Removed <br /> Type ot peAorator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> _ � <br /> GroutingMaterial����`-�/����f/om y,,,L� ro �� k. yards �Z bags <br /> from to tt. yards bags <br /> trom to ft. yards bags <br /> from to__ tt. yards bags <br /> REMARKS,SOURCE OF DATA,dFFICULTIES 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 /> '-'(_. /. i. <br /> �� � � This well or bonng was sealed in accordance with Minnesota Rules,Chapter 4725. The informalion contained in this report is <br /> �' �QO� true to the best of my knowledge. <br /> ������ <br /> ' Don�Stodola We1lDrillin Ca. Inc. 27I72 <br /> � Contractor Business Name License a Regisbafion 170. <br /> �� / � <br /> ! �-�<,. - �-29-0 <br /> A o' resentafive SignaN _ �ete <br /> Ji� �ntQnson <br /> LOCAL CO�Y H �7,���y�� Name ol Person Sea�ing Well a Bonng <br /> B� V <br />