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MINNESOTA DEPARTMENT OF HEALTH Mmnesota Well and Bonng �H � `��^O � <br /> YYELL OR BOIi1NG LOCATION Sealing No j� L <br /> �,,� WELL AND BORING SEALING RECORD Minnesota Unique No — <br /> Minnesota Statute.s,Chapter 1031 or W-series No. I <br /> � ILeave blank il not known) _J <br /> Township Name TownsMp No. Range No. Section Na Fraction�sm.i Ig.) Date Sealed Date Well or Bonng Constructe� <br /> � + �J� �} . C..� /" �� , _ <br /> ! <br /> Nunencal Streel AAdress a Fire Number and Gry ol Well or Bonng Localion ' <br /> Depth Beforr,Seahng �.�y> _N. Original Oepih - ���' n <br /> SAow enad loration d�aell a Donng Sketch map of well or bonng AOUIFER�S) STATIC WATER LEVEL <br />� n section gnd wrM�'X'. locauon, showing property ,�Single Aywfer ❑ MWhaqwfer <br /> lines,roads,and bwldings. <br /> N WELUBORING �Aeasured ❑ Eshmated <br /> � Y� _ <br /> '�Water Supply Well ❑Monit.Well <br /> -�- -�- -�- -'-- f ❑ Env.Bore Hole ❑Other �' �'�� fl. �bebw ❑above land suAace <br /> W --'r-- -�-- -T- -i-- E t��d��.' �� CASING TYPE(S) — <br /> 4. ;.s' <br /> -T- -i-- -i-- -i— � � ❑Steel ❑ Plastic I�Tile ❑Other (�%; - `�fr� <br /> � � � � um�e .. .,';:. � . .. <br /> ��t. <br /> -�- -+- --I-- -�-- � . -�, . .� CASING <br /> t"` �-% Diameter Depth Set in oversize hole? Annualar space inrtially grouted? <br /> S .��.+�-`in.from f___� to�•� ft. ❑ Yes �No ❑Yes ❑No ❑ Unknown <br /> ���� <br /> PfiOPERTY OVYNER'S NAME ��� in.from _ " to ' `� ft. ❑ Yes 0 No ❑Yes ❑No ❑Unknown <br /> Rape�ry o.rers maing address a dAferent Vian we�l�ocation address indicated above. -'� in.from �',�-� to "� � R. ❑ Yes Q No ❑Yes ❑No ❑ U�known <br /> SCREEWOPEN HOLE <br /> Screen from to R. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ������ � Rods/Drop Pipe ❑Check Valve s <br /> ( ) ❑ Debris ❑ Fill ❑ No Obstrudan <br /> YYN owrfs addiass R QllsierM t�an owners address indicatetl above. � l-� �'�'� ' <br /> m�irq property Type of Obstructions(Describe) �` <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP <br /> :i �.� �: � .�.1 <br /> Type •/ -' <br /> ������ �� HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> q not laq�wi,iidra�s siYtiedlortnaeon bg}rom nearDy well or bonng. METMOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> . �No Annular Space Exits <br /> Y w �f �'� ❑ Annula�space grouted with tremie pipe <br /> ❑ Casing PeAoratioNRemoval <br /> in.from �o ry, ❑ Perfaated ❑ Removed <br /> in.from to ft � ❑ Perforated ❑ Rertroved <br />� <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> � „� � �J <br /> GroutingMatenal `�'��`�'' S from to� tt. �-^�^� yards bags <br /> 1 <br /> ��.�.'�/. :�JN, (<• ffWll t0 �I- y8ldS _;_„�;1 bep8 � <br /> trom to n. yerds degs <br /> from to_— ft. yards bags <br /> RHIAitl�B,80UiCE Of DAT/�OFRCULTIES IN SEALING OTHER W ELLS AND BORINGS <br /> Clther unsealed and unused well or boring on property7 ❑Yes ❑No How man�/t <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> - . This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The i�ortnation oorMained in Miis report is <br /> . true ro t�e best of my knowledge. <br /> s t,,;,:;. l�on Stodola t�el2 Drillin� Co. Inc. 271.72 <br /> �,)�� � � ,° Contredor Business Name > ,� Lioenss a Re¢stra0on ivo. <br /> .. � :, �',` �...�--`,.,,,����� Z� �* �1 <br /> f � � ` � <br />�t oriz R resentative Signature.- De/s P <br /> H ����A O Name o!Person Sealing Well or Bonng <br /> LOCAL COPY �� <br />:� tE-01�-03 2/97R <br />