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. , . . Jt . . .. .. . , , . . . .. • � . . _ . . . <br /> �' wELL oR BORwG LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 3 818 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minn�esoNa Unique Well No. <br /> Minnesota Statutes,Cha ter 1031 or W-series No. <br /> �pin P (Leave blank�I not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> 4rcmcr li7 tt�G6 4 _ � SF (� U <br /> � GPS Latitude degrees minutes seconds �t„� � <br /> '�. LOCATION: Depth Before Sealing ft. Original Depth ft. <br /> Longitude degrees minutes seconds pUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> .�n � �� � �� � W1E�LU�BORING �easured ❑ Estimated <br /> /4V �7�vvater Supply Well ❑ Monit Well �-1 � <br /> �' Show exact location of well or boring Sketch map of well or boring 7` �y..� <br /> 'i in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other �fL �below ❑above land surface <br /> lines,roads,and b ings. <br /> . N f; � CASING TYPE(S) <br /> _ �1-!vro !` <br /> teel ❑ Plastic ❑Tile ❑Other <br /> W —�- - -- - -- -- — E - - - WELLHEAD COMPLETION <br /> , , .._�_ <br /> � � � � � ��='>�'"�� Outside: ❑Well House Inside: ❑Basement Offset <br /> -�-- -�-- -;— - i— � <br /> � � � � �mile ,,,.,_.�,.._.._ , <br /> , M,�.,_ 1 ❑ Pitless Adapter/Unit �`Well Pit <br /> -;-- -�— -1-- --i-- � �� <br /> ❑Well Pit ❑Buried <br /> S <br /> �r m�e� �__,_._� ❑Buried .. <br /> � <br /> PFOPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � Dia�er�! O Depth �� � Set in oversize hole? Annular space initially grouted? <br /> :'. Property ow er s mai i g a s i an w ion d ss� e above <br /> in.from t0 ft. ❑Yes �i1 No ❑Yes ❑No ❑Unknown <br /> T` <br /> in.frOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.f�Om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> , WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> �/� r � <br /> '�Well owner's mailing address if different than property owner's address indicated above Screen from�t/ 10 ( ` ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> � _� <br /> Type of Obstructions(Describe) �/�,L2,!/�r� /�''r �� �- �j�F�� <br /> r <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? BS ❑ NO Describe <br /> FORMATION <br /> �'.� If not known,indicate estimated formation log from nearby well or boring PUMP ^ <br /> � ,�� Type J F 1 { �� <br /> f � �"� � Removed ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> + in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> ; � / <br /> ��( � G <br /> Grouting Material N���L���,Arom�—to�.LJ ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> ' REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes No �.How many? <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 Stodols Wel.l I}c311ing Co., Inc. 27i72 <br /> Contractor Business Name License or Registration No. <br /> � � � <br /> ori presentative Signature Date <br /> � 1 1 ,4`- �%�7 �: t.�.-��,,,?-�Y..�-- : <br /> ' LOCAL COPY H +i. + �s � ` <br /> Name of Person Sealing Well or Bonng <br />