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BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 110 9 6 6 <br /> ame <br /> WELL AND BORING SEALING RECORD Sealing No. <br /> Minnesota Unique No. <br /> �j� Minnesota Statutes,Chapter 1031 or W-series No. <br /> '�p+�+ (Leave blank it not known) <br /> nip Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> cono s.I� 23 zl ?�i-�6o,, <br /> ierical Street Address or Fire Number and City of Well or Boring Location f � <br /> Depth Before Sealing ��„�_ft. Original Depth ��� ft. <br /> �- <br /> .how exact location of well or boring Sketc�map of well or boring A�UIFER(S) STATIC WATER LEVEL <br /> n section grid with"X". location sh wing property Single Aquifer ❑ Multiaquifer <br /> lines,ro nd buildings. <br /> N WELUBORING Measured ❑ Estimated <br /> � � � �� Y =� Water Supply Well ❑Monit.Well � <br /> _Y_ _T_ __l__ � ,. /� <br /> � � � i <br /> ����--�� ❑ Env.Bore Hole ❑Other �G.�ft. �below ❑ above land surface <br /> � � � � / "�-(-- <br /> W -�-- -�-- --i-- --i— E �" `� '�. . <br /> �, l ..,. CASING TYPE(S) ' <br /> � i � �� <br /> � <br /> � � i � � �, \\. � �.:� <br /> --�- -�-- -�-- --�— t� v �a�; \` � Steel ❑ Plastic ❑Tile ❑Other <br /> ;4 mile •. �'�> <br /> —�- --�-- --�-- --�-- � ��.` .3 ��, .. CASING <br /> � Diameter Depth � Set in oversize hole? Annualar space initially grouted? <br /> L� """��J��� / <br /> pk--1 mile�e � �"� in.from� ro / 7f ft. ❑ Yes '�Vo ❑ Yes ❑No ❑ Unknown <br /> � � �� <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> Property owner's mailing address it difterent than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> � � / <br /> Screen from��to�_ ft. Open Hale from to R. <br /> O BSTR U CTIO N/DE B RIS/FILL <br /> WELL OWNER'S NAME Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill ,1�/�,��{��/���/7�� ¢' �)��� <br /> Obstruction/Debris/Fill removed? Yes ❑ No <br /> PUMP /} <br /> TYPe—,�szeV' / lJf/ �{� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indirate astimated 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. r .— <br /> - ❑ Annular space grouted with tremie pipe <br /> � ❑ 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) <br /> / ) <br /> Grouting Material �! _ �— to ,���ft. yards J� bags <br /> r � <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 o <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFI A ON <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 Stodflla ��TE2I Ari2lin� Co�. Ir�c. 27I72 <br /> Contractor Business Name License or Registration No. <br /> -�� � %". � .. r_.,. <br /> -+3'��_./� <br /> � , ;. � ,-_ . fi `��'' �a--,� �r`J ..� '� ��rs <br /> �hz.d�eplQ'seMabve �gnature Date ' <br /> �. _..��a��, <br /> �y Name ol Person Sealing Well or Boring <br /> LOCAL COPY H � 1 O � � � <br /> HE-01434-02 10/95R <br />