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... �...,. ,,-. y -q4 .. � ,p� }�._� <br /> r ., .�. ..' � . <br /> . <br /> . <br /> , :" �• q <br />.,:.. .�,,. �- . . , ,.. ,:.�„ � ..`r�a, � .. .. . :..� '. . .. � � ' <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring 1366 4 J I <br /> WE��oR BOF�N��o�AT�oN ___ WELL AND BORING SEALING RECORD Sealing No H <br /> Counry Name <br /> H�411@ 112 Minnesota Statutes,Cha ter 1031 Minnesota Unique No. � <br /> j� p or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction�sm.-s Ig.) Oate Sealed Date Welt or Boring Construded <br /> r�no �17 23 2 ,, ,, �i/17/98 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ^7 <br /> ��V� .S�l�t 't'�I Z�� �r 1 V'4'� Depih Betore Sealing 1 /� ft. Original Depth 1�l ri. � <br /> Show exact location of well or boring Sketch map of well or bonng AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". �J`� location, showing property �Single Aquiter ❑ Multiaquifer <br /> lines,roads,and buildings. <br /> N WELUBORING �Measured ❑ Estimated <br /> � � � � [$Waler Supply Well ❑Monit.Well <br /> II I , ������S ' ❑ Env.Bore Hole ❑Other _ 44 tt. �elow ❑ above land surface <br /> W --�- -i-- -i-- --i— E j . CASING TYPE(S) <br /> � � � � .� ' <br /> � � <br /> -�-- -�-- -�-- --�-- � ; [�Steel ❑ Plastic ❑Tile �Other <br /> � � � � <br /> u mde � <br /> --�- -�— �-- --1 � ' -r .x`�.. �t �� CASING <br /> - -. r .i...,�" <.�.'_`:._. <br /> �-���-- ���� � � Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> S ��J"� r � � � ��7 V Yes ,Y No Yes No Unknown <br /> �t mae—�e _ _. � ` � �; � in.from to fl. ❑ L7' ❑ ❑ � <br /> I <br /> PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> i�ar� H.o�rar� <br /> Properry owner's malling atldress if diNerent than well location address indicated above. in.from to k. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> �t30 S. �'1 uth ltaad <br /> Mi�netdnKa, �� 55:iU5 SCREEWOPENHOLE � <br /> Screen from+5L5L to�i� ft. Open Hole from to tt. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME <br /> [$Rods/Drop Pipe ❑ Check Valve(s) ❑Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address i�di8erent than properry owner's adtlress indicated above. Type ot ObSlruCtions(DesCribe) � �0• .�1�e dn�� �i r e <br /> Obstructions removed? � Yes ❑ No Describe <br /> PUMP <br /> Type �uiom�rsible <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO '�Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> It not known.indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> C�r 1��i � ,,�l �No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing PerforatioNRemoval <br /> in.from �o h. ❑ PeAorated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of peAorator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) <br /> Grouting Material ��'�t j'�'$� from 1�1 to V k. yards 1� ba s <br /> 9 <br /> from to tt. yards bags <br /> from to ft. yards bags <br /> from to-- tt. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> 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 /> HES Weil yrillin� 1'll7b <br /> ,, ' ' :����_ f�'��0. <br /> ontractor usiness Namg License or Registr on <br /> /t <br /> Authorized Representative Signature Date <br /> J d;n�� L�a <br /> LOCALCOPY H <br /> 13 6 fi 4 9 Name ol Person Sealing Well or Boring <br /> HE-01434-03 2/97 R <br />