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4865 Pilot Knob Rd - Well & Boring Sealing Record .♦ € .. : � ' _ . , e'v�L OR B R1A1G:L'{3CATlON MINNESOTA DEPARTMENT pF HEAL"�'H : Minriest�Ya'Y�ei!and Bt�ring � ������ Cou Nam� ����.��D B�I�I�1G SEA�1�� #�ECORD nin�t�ta Unique=We�l t�o,. ,. MirinesCtta�taYutes;�t�p�e'r t�3 °F,�����i ` ip Na ' T' o Fta" 'N S n(sm-+,.Ig. Date.Se .r.»'"' Date Wcli r Bnn��Cqp�t�i, : �. ..,, . � .�',�' ��' ,. :.: "'. � � .�. �" ���.. ; '�,,, �� '�,.. �..r ,. � , �PS LOC I -�cimal.tie�eees�to.tour decimal piaces) : �ejst6 8efore$ealing ��� ft. Origjnal��h �� (i Letitude �cn3giCude A S�) STA71C WAY£Ei�EY��. :: � ��,�� � Numerical.�tr t Ad r e N r apd i of, etl orp,�ing Qca �] ngle.Aqui,fer Q MultPaqurfer � ��f��" �!�� 1��� RING �ureii �Estimafed Date Measur#:tl� � �' �J "� � er-9upply Weil[]RAon�i�dett ' '' ��Show eraet �2tion of well or bbcing Slt�tcFi'map of weq s�[ '�9 E�v:Bore Hole --���_��� in section grk3 h"X.° location,showi t�rty n ❑Other �above land surtace lines,roads,a� '�dirSgs. N CASINCi TYPE(5) r ; �' ����� ��3� o�hs� : - - � . � . � WEI_LH6Ai�CUMPt�UN : ..' w ; e �r� -� •--- ---: � �� rtle Well liouse =j At C�,ra , � �t4 ' � 1n81� t{?Hset de : 'G taiie ❑Pitless AdapterlUnR ��ucfetl �Well Pil ,- -- - l � ���� ' ` �' � D we��Pit x . , Q�er �-1 Mile---� ... Q.�kf'�t , P NAM �{1S1NCi(Sj pia er Ctepi. � Sat in tnrer�kze=hote�. Afawlar space trt�@�gro��? � '�:PtnP@r2Y�={lwner'$r»��n���dress if diHer9nt th� ivell,lo9atbn ddra ' cat e.hdv5.� ''�,. �in,irQm� f0 ���� , [.�.'fBS, {�NO []Ye5 ❑MO �Wvri �. , � � ����� �,�� ��• ������ in.from tb - 8, �YeS �No` []'lss�} fl�to r.�].�Jnkrroxm � e � ��� �%��� in.frorn ta �t: _ �'/�s (�No �Yes �No ❑Unknown �I WE N' M SCREEI4lOPE►� ` ':.. '�...� �ng add'resst�'fiiHerent than propa,'Ety' ,e�s address indicaied above��... Screen�irOm t9 �C��1en Wpt�frorr� 10��''... �'. it �. i �' OBSTRUGTIONS ' ` � ❑RodsNrt�Pi� �j Ghedc Valve(�) �=#J�:Eans'' �FlII [�'�6structio� ' �.'.' .; ' , .. ' T3�4i;4kr'�ctl�'ias�Des�l�3'. , i t. GEQLfl�IG.�.MATERIAL �y�q, HAADNESS OR -FRAW TO �bs[r�et�s re[n�vetl7 �3Yt±s ��d, ;aescribe' � � FORMA710N.. � 't . ., '�� i... . . ., ���', . _ � . ...... i � If noi known ` i�ate esdmatsd#omm�eatiara.fog#rom a �Q�:tt��. . ������ y r�vetl ❑Noi Present [�C7#taer.' ':..' M D'�►SED TO SEAL ANNW�pR'S�'ACE BE'iWBEN 2 CJ}�1Nta"Sy�iI3 t'rASING ANb BflRE HOl£ �. Q,Aortu,lar Spat�Exists Q�nutar Space Groutet�x+i�Tr�rare�F'� ° [�Casing Pei�tora�ll�mo4ai, �, . ' in.from ,' to s 1t �Perloratatl r , �J F�emoved I fri.from � ..� to ' tt; ..°` D P�rksiated �Fiemoved � i �fype U�P$r�4Crlfbf r.. VAAIANGE Was avariaY��jranleti:ictam the M�H for ftiis,�sJl?^�'j Yes C]No TN# GROUTIt�G INA3'fRIAL(� ne b�ai!' 'en#�94 Ibs.,one bag ot b�tnn�a �1�+s.) Grouiing M�48rial���� '. io �.�ds. t>ag'� � ". °. .' r ' from t4.. � ` y�t: �g� . �' iram to ft. yar�fs b�s- OTHER W£�.LS 1►MD BORIN�S; , REMARKS, URCE-flF'DATA,flIFFl�1lL�ES IN SEALING (?�Fier uSt��aled and Unusec!}we11 flr Moring on pTtsperly? []Yes . " HOw many?' � ! LICENSE[t pR#�EGISTEREt?�NTFi��TQR CERT7FHCATIOPI'' 73���1(br t�sing was�ater���ccoeda�ce:wi[h b1i�nEsota Rulss,Chapter 4Y25.The informaFion cor+tamed fn this report �t�s.�G the iaest ot my knticvledge ���� .� Lice� Susirre me Licen' a�` `tnn ��w���"�'" '�'"..�� '��".+' � g � Ce1�l#!Qt!Aspresen�#iwe Sigtiattir8 '; ' Cert77led Rep.No. Data ' ' #�f'ORT�-f1l.E �+�ti5P�R7Y � �������, r �APERS- C? E�t GOPY ������ t�ame v�Qr �eaJi�j 1+VeU or 8wi»y . `. ti£�1434-i4 rIC#140-0423 �i73A �