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wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 2 5 6 3 <br /> County Name <br /> WELL AND BORING SEALING RECORD Sealing No. <br /> Minnesota Unique No. <br /> Minnesofa 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 /> t� i i i _ �; _ � / �,� �r, , <br /> Numerical Street Address or Fire Number and City of Well or Boring L.ocation <br /> � Depth Before Sealing ��� " ft. Original Depth � !! � ft. <br /> 6 i. � _ <br /> Show exact location of well or boring Sketch ,ap of well or boring ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property �ingle Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. <br /> N i WELUBORING �'Measured ❑ Estimated <br /> � � � ....,- {�Water Supply Well ❑Monit.Well <br /> � � „� ) [/�/ <br /> r_ _�' "�_' '_�'_ ' ..._. '. 1..r VO 2f1 � • �� � .. <br /> -��"`- ❑ Env.Bore Hole ❑Other ft. �below ❑ I d s rfac ..._ _��. <br /> W -�- -�-- -i-- --i-- E '; �� CASING TYPE(S) . <br /> � � x � <br /> , : _ <br /> I I I - � 1 ,n�. � <br /> --�- -�-' --1-- --�- ' L.J� [�Steel ❑ Plastic ❑Tile ❑ Other <br /> � 'b mile,., <br /> --�- -�-- � ;' � CASING <br /> --�-- ---{-- <br /> -s � Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> LL"" S """��1��� � � , � � <br /> p�t mi�e-�n � in.from �,,:� to J�L� ft. ❑Yes �Jo ❑Yes ❑No [�,�LJnknown <br /> I I <br /> PROPERTY OWNER'S NAME ;\ in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> r �" : <br /> Property owner's rPf iling address i different than well location address indicated above. in.from to ft. ❑Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> � �-r ;�-�', Screen from ro ft. Open Hole from ro ft. <br /> O B STR U CTI O N/D E B R I S/FI L L <br /> WELL OWNER'S NAME � IA Obstruction Debris <br /> :.J� � ❑ ❑ Fill ❑ No Obstruction <br /> : y... � <br /> Well owner's mailing address if diHerent than property owner's address indicated above. Type of Obstruction/Debris/Fill f,J�' j�� ' a�' ��(� ��- �- <br /> �-,�- <br /> Obstruction/Debris/Fill removed? � Yes ❑ No <br /> PUMP i <br /> Type � _ Y <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 boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �..No Annular Space Exits <br /> r t� <br /> . ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to tt. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> � 4' , <br /> Grouting Material �-, ��� from (� to�a ft. yards �.. bags <br /> from to ft. 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 �,[Jo <br /> �.,,y ; , LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> �.J�.. '� . � � . . <br /> � � This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> [rue to the best of my knowledge. <br /> 1 � ' r j'' ii � ,� -� � : t ! <br /> Contracfor Business Name License or Registration No. <br /> f .... � ;: _,��� -r,.- �-r i <br /> Authorized Representative Signature �'-' Date <br /> � � � r <br /> r: r-4 n Name of Person Sealing WeH�r Bonhg ��+� � � <br /> LOCAL COPY H i � �'` �"; �j � <br /> HE-Ot 434-02 10/95R <br />