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.. �;',.. ` ' �,: ...�.; �,?��s:�' <br /> . <br /> ... .. . . . _ -. � ,. <br /> . < <.: ..... .. .,...,. .. . . . _:. � . ,..�. .. . :.-... > .,._ ._- :. ,... ,. . .,.._,. .�,�.:. . .,... .�..z._ . � <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring r �C� ,f! ��� � <br /> .LL OR BORING LOCATtON S881ing NO. i H— a��, � <br /> unty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. — <br /> Henr�epi n Minnesola Sfatutes.Chapter 1031 or W-series No. �– � <br /> (L�a:s deN�X rwt known) <br /> a Township No. Range No Section No. Fracnon�sm.-s Ig.) Date Sealed Date Well or Borinq Constructetl <br /> '� �r� z3 i� 4�-a�z� r u � <br /> Numencal Sheet Adtlress or Fire Number and Ciry ol Well or Bonn�yoc`at��ory� � � <br /> 3452 f j 2 V 4��.�J P 9 � ' — 9 P �� -- <br /> Li�lA�8t0� Ave• � y�p�a De th Before Seal�n fl Ori inal De th fl ' <br /> . � Show ezact location of well or bonng 55391 Sketch map of well or bonng A UIPER(S) STATIC WATER LEVEL <br /> in section gnd wrth'X'. I�cation, showing property Single Aqwter � Mulimquder <br /> , �ines,roads,and buildings. . - � , . , , <br /> ; N ry,— WELUBORING �Measured ❑ Estimated.,.�'. �• ���� �" � " <br /> � � [�Water Supply Well ❑Monit.Well / <br /> � n Env.Bore Hole <br /> ❑ ❑Olher _ _�R. �i below ❑ above land surlace <br /> W --�- -i-- -i-- --i— E CASING TYPE(S) <br /> �' --�- --�- -�-- --�-- � . ., �teel ❑ Plastic �Tile � Other <br /> � I I I }lmile � . <br /> —�- -j-- -�-- --�— � CASING�S) <br /> ' ' Diameter Depth � Set in overs¢e hole9 Annular space initially grouted7 <br /> �(.—i mxe� .. =-�'i;_-r .�J?..y� � n.from�_ to� ft. ❑ Ves �No ❑ Yes ❑No ❑ Unknown <br /> I <br /> pWIA q�y��rg Clpq� asa.�������--�-�9�Z^A (1�,T/ �n.trom ro k. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> �t` I -s r <br /> Property owner's maiGrg address if diHerem than well location address intlicated above. in.from to ft. ❑ Ves ❑No ❑ Yes ❑No ❑Unknown <br /> SCREEWOPEN HOLE <br /> r <br /> Screen from�.L to�,it. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME (�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well ownefs mailinp address i�diHerent t�an property owner's atldress indiceted above. Type O(Obsiructions(DesCribe)��V N r rL �r��� �`" / �U/� �1 � <br /> . Obstructions removed? �'es ❑ No Describe <br /> PUMP <br /> Tvve .�U�.; f-'t�(j'�1' <br /> GEOlOO1CAL MATERIAL COLOR HARDNESS OF FROM TO +a Removed ❑ Not Piesent ❑ Other <br /> FORMATION <br /> N rat known,indicete estimated fotmatbn log irom nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � : f�Jo Annular Space 6cists <br /> `�-� �"�0' ❑Annular space grouted with tremie pipe <br /> � ❑Casing Perforation/Removal <br /> in.trom to R. ❑ PeAorated ❑ Rertroved <br /> in.from to n. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ othe� <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> A' /'�'' rl�t �,�} / 1 <br /> Grouting Material !"���� (t���`iFortS "" to�ft. yards ` O bags <br /> fran to R. yards bags <br /> from to R. yards begs <br /> from to__ fl. yards begs <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property7 ❑Yes o How many? <br /> LICENSED OR HEGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this repoA is <br /> true to the best of my knowledge. <br /> Don Stod4la Well ilriiling Ca. , Inc. 27172 <br /> Contractor Business Name � License w Registration f:o. <br /> ,_ �"'?/ __ s r-� � ,.� t �� � � <br /> •,,'� � /' -'�-`'' 7 r i� �._.,d � t '�✓ <br /> �nta Signatu Dete <br /> �` - r..'��... ...... ;�Lf �,� , Ja,_„J.i-`l�w. <br /> LOCAL CC?Y H 18 4 7 3 0 Name o�Person Saeling Well a Bonng <br />