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�' - - - � _ <br /> WELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �18 414 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnle9oNa Unique No. <br /> Minnesota Statutes,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 /> Qrono 117 23 t}8 45-0'027 /� 9' <br /> Numerical Street Address or Fire Number and City of Well or Boring Location � l �, ♦ � <br /> 3'!UQ Bi r ch Lane QXOn� 5 5 39I Depth Before Sealing • 7 R� R. Original Depth /�_7 ft. <br /> Show exact location of well or boring Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property Single Aquifer ❑ Multiaquiter <br /> ��y s, nd buildings. <br /> N „�--�"'� �,� WELUBORING Measured ❑ Estimated <br /> ' ' Water Supply Well ❑Monit.Well � <br /> _ _ _T_ _ __ __l__ w <br /> T � J <br /> I I ! I ❑ Env.Bore Hole ❑Other_ _.�, s�ft. �below ❑ above land suAace <br /> __f_ _l__ _l__ __l__ -• .r <br /> W E -� ` CASING TYPE(S) <br /> � � � � e',�. <br /> � � � � �� <br /> --�- -�-- -�-- --'�-- ,?,L� Steel ❑ Plastic ❑Tile ❑Other <br /> 14 mila ' <br /> --�- -�-- -�-- --1-- � CASING <br /> �� ._:w,. <br /> �->'� Diameterf Depth / Set in oversize hole? <br /> S . Annualar space initially grouted? <br /> �r mxe--q�e �� , - � �_ in.from � to�L ft. ❑ Yes �No ❑ Yes ❑No ❑ Unknown <br /> I <br /> PROPERTY OWNER'S NAME in.from to tt. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> �i13 i ward 4?1-i3��i <br /> PropeAy owner's mailing address if ditterent than well location address indicated above. in.from to ft. ❑Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> r,,, i � <br /> Screen from�to� ft. Open Hole from to ft. <br /> OBSTRUCTIO WDEBRIS/FILL <br /> WELL OWNER'S NAME �Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if ditferent than property owners address indicated above. Type of Obstruction/Debris/Fill �/�/V'��< /""l-NT � V LJ <br /> Obstruction/Debris/Fill removed?�,,.Yes ❑ No <br /> PUMP <br /> Type <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 HOLE: <br /> - � �No Annular Space Exits <br /> ._...,� ' _�.-1' �"� ��'� ;`y�..::, <br /> j1 <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing PerforatioNRemoval <br /> in.from ta ft. ❑ Perforated ❑ Removed <br /> in.irom to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> ��' ���^'' f <br /> Grouting Material/�'���� �����1Fom � t���,j_ ft. yards � bags <br /> from to R. 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 information contained in this report is <br /> true to the best of my knowledge. <br /> Don Stodola tde21 Drillin�; Co. , Inc. 27172 <br /> Contractor Business Name License or Registrafion No. <br /> +_...__�% . - ; ,«.., <br /> ''�-- . .� �'� �,` t j l <br /> Authorized epresentative Signature Date <br /> 1 <br /> ` 'f .,. _ � ;.�_.i,1�� ...�; <br /> LOCAL COPY 118 414 Name o/Persoq"Sealing Well or Bonng <br /> H <br /> HE-01434•02 10/95R <br />