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wELL OR 6tORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 819 5 <br /> . ri WELL AND BORING SEALING RECORD Sealing No. <br /> Coun Name <br /> Minnesota Unique No. <br /> F�I121"�'�lIi Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank ii not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> �E�% ��} � � �� % % % <br /> Numerical Street Address or Fire Number and City of Well or Boring Location � "� i <br /> ��/ ShcYr�li_ne �1L'� �C?I1CJ� �. .�i���� Depth Before Sealing � 7� ft. Original Depth �/ � ft. <br /> Show exact location of well or boring Sketch map of well or boring AQ ER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property ingle Aquifer ❑ Multiaquiter <br /> ; � lines,roads,and buildings. <br /> N ;� WELL/BOHING �vleasured ❑ Estimated <br /> � � ; � :�� '�NaterSupply Well ❑Monit.Well l . <br /> � --;-- <br /> — - -�-- - <br /> �--�----� ❑ Env.Bore Hole ❑Other �� ft. �ielow ❑ above land surface <br /> W -�-- -�-- -i-- --�-- E '4�.j 1. _�.„, CASING TYPE(S) . <br /> � � � -•---- � <br /> i , <br /> � � � �_ `, <br /> i , <br /> '�-- -�-- --�-- --�-- \ �/ I� IXSteel ❑ Plastic ❑Tile ❑ Other � <br /> i i i �mlle � _-... j f s-1 <br /> -�-- -i-- --�-- --�-- � � ,.�----'__`" ..j i s..�.... CASING <br /> Diameter Depth j Set in oversize hole? Annualar space initially grouted? <br /> r <br /> �r�—1 mile�'a � �r in.from_� to�� ft. ❑ Yes �No ❑Yes ❑No ❑ Unknown <br /> i <br /> PROPERTY OWNER'S NAME in.from to ft. ❑Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> RC71�Zt Ydc�d� & �SCX:1 � <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> ���i I .71N��111� U�„1V� SCREEN/OPEN HOLE <br /> / / <br /> ����� �, ,�j�3'�j� Screen from�to_.�.�� ft. Open Hole from to ft. <br /> ��J—ES J�J 3 083TRUCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill �Qlo Obstruction <br /> / � <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill <br />� Obstruction/Debris/Fill removed? ❑ Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ot 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 /> - :'� �L1� <br /> __ ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from_ to ft. ❑ Perforated ❑ Removed <br /> in.from �o n, ❑ Perforated ❑ Removed , <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> �� / <br /> Grouting Material 1,�y�yC�f��dL� from � to� ft. yards � bags <br /> �%�J <br /> from to R. yards bags _ <br />� from ro 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 properry? ❑ Yes o <br /> LICENSED OR REGISTERED CONTRACTOR CERTIfI ATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information conlained in this report is <br /> true to the best of my knowledge. <br /> DC�Id �'�'C�Ld� �dF..LL URII.t.IIvG C�;., L�iC. 4 7 7 7 2 <br /> Contractor Business Name _ License or Registration No. <br /> F <br /> s�/'l .l_�:� - 1�,��'�� � ....� � ' ; f <br /> �th e�trve Sigrt�dture-'� �Date <br /> . � � <br /> � r � Name of Person Sealing Well or Boring ' " � � "' y - � — -�� <br /> LOCAL COPY H � i,� g � ,� 5 <br /> HE-01434-02 10/95R <br />