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.,� — <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ��f1��� � <br /> - WE��oR Bop�N��o�AT�oN _ WELL AND BORING SEALING RECORD sea�i�g No. j H U <br /> County Name Minnesota Unique Well No. -- <br /> Minnesota Statutes,Chapter 1031 or W-series No. � � <br /> Henae in ���n�k�, _— <br /> Township Name Townsh�p No. Range No Section No. Fraction�sm.-s Ig.) Date Sealed Date Weli or Bonng Consiructeh <br /> l�ound 117 23 8 � �� 8/15/00 F��CE) <br /> Numencal SVeet Address or Fire Number and City ot Well or Bonng LocaGon /�f'(' Q . <br /> 3826 Gherrp �ve, ���d Depth Before Sealing I� fl Original Depth �4 HU(7 � v �oo� <br /> Show exact locahon of well or bonng ��i�, Sketch map ol well or boring ApUIFER(S) STATIC WATER LEVEL p <br /> in section grid wrth"X". � j 1� locahon, showing property Single Ayuifer ❑ MulOaqwfer MOUND FLt�i�NIIVG & INSr, <br /> �- � lines,roads,and buildings. <br /> N WELUBORING �Measured ❑ Eshmated <br /> �Wa1er Supply Well ❑Monit.Well <br /> I I I ' � � ❑ Env.Bore Hole ❑Other _ __3II_R. ,�below ❑above land surface <br /> W --�-- E CASING TYPE(S) � <br /> � � <br /> , � � � � <br /> ^ —�- -�-- -;-- --�— � Steel � Plastic �Tile �Other <br /> �� I � � � �e mile <br /> —�- -i-- -i-- --�— � � CASING(S) <br /> Diameter Depth Set�n overs�ze hole? Annular space initially grouted? <br /> S nn <br /> ��mNe� � �,1�..�/Y \� � in.from__�� to_��_ R. ❑ Yes �J No ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> Di k �ians ti <br /> Property owner's mailing aadress If diHerent than well location address�ndicated above. in.trom to tt. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> Screen from�to� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Dro Pi e <br /> p p ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if diHerent than property owner's address indicated above. Type o}ObslructiOnS(Desc�ibe) P f n� � i�et. <br /> Obstruclions removed? (�Yes ❑ No Describe <br /> PUMP <br /> Type T s.� <br /> OEOLO(i1CAL MATERIAL COLOH HARDNESS OF FROM TO ',i�Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> N not known,iMicate esBmated tortnatbn log from nearDy well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> in.from to R. ❑ Perforated ❑ Removed <br /> Type ot peAorator <br /> ❑ other <br /> GROUTING MATERIAL(S} (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Matenal pOl�tl�n� from � to� h yards ��� bags <br /> !� -- irom to ft. yards bags <br /> irom to R. yards bags <br /> from to__ ft. yards . begs <br /> REMARKS,SOURCE OF DATA,DIFFlCUlT1ES IN,SEAUNG OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes �No How many? <br /> �.,��-,;,f' LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or bonng was sealed!n accortlancs wirn Minnesot2 Ru1es,Chapter 4725. ?he informafior cr,�.:-� -��- �- - ---- . <br /> true to the best of my knowledge. <br /> t , - 88S �ieli Drf 111�g 27276 <br /> Confractor Business Name ,.� L�cense or Regisfration ia�. � <br /> ' ` t <br /> �.,��-'-� ��-��� �����t� ' <br /> Authonzed Representative Signatwe Dafe <br /> ..r._ �obert S. Stedo2�sL� <br /> LOCAL COPY u�����A I Name ol Person Sealing Well or Bonng- <br /> r� � <br />