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Minnesota Well and Boring H 5 9 4 9 � <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. <br /> CouNy Name WELL AND BORING SEALING RECORD M��neso�a u��qUe No. <br /> '�a���j Minnesota Statutes.Chapter 103/ or W-senes No. <br /> ILeave blank if not knownl <br /> Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br /> ���r��� ��p �� �g �4�_����4 ��� or Boring Constructed <br /> c7 <br /> Numencal Street Address or Fire Number and City of Well or Boring Location �j <br /> _ 3265 County Raaa 6 Long Lake, �. ��3�j Depth Before Sealing ��'" fl Original Depth �� fl <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level �Accurate <br /> in section giid with"X'�. bcation,showing property lines. <br /> N y�� -j roads.and buildings. ❑Approximate <br /> � � , , <br /> `—� ��� i . <br /> -,- -,- -;- -; <br /> U� �Single Aquifer ❑Multiaquifer ��ft. � below above land surtace <br /> -'- -�- -i- -'- v iJ��!I CASING TVPE <br /> W i i i i E <br /> � � � � T <br /> _i_ _�_ _r_ _i_ � f <br /> i i i � j �Steel ❑Plastic ❑Tile ❑Other <br /> �mile <br /> -'- -;- -`- -'- � � _' i32 136 <br /> S ; Screen from to R. Open Hole from to ft. <br /> c <br /> N—7 mile—� . ,, i t OBSTRUCTION/DEBRIS/FILL <br /> �Obstruction ❑Debris ❑Fill -�- <br /> PROPERTY OWNER'S NAME <br /> }�U71 �E.'I.C��"tt7E'.Y' f1 �q� <br /> Type of debris/obstruction � r�� �/r`���r <br /> Mailing Address i(different than property address indicated above. <br /> ObsVuction/Debris/Fill removed? �Yes ❑No <br /> PUMP <br /> �Removed ❑No�Present ❑ Other�;..���,_�_. <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space milially grouted? <br /> I(not known,indicate estimated formation log from nearby well or bonng. <br /> �• in.from �_to �— fl. ❑Yes �No ❑Yes ❑No ❑Unknown , <br /> in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> [�No Annular Space Exists <br /> ❑Annular space grouted with iremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑PeAorated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> Grou�ing material T1AA�' t'A7►1PM'1't' from �_to �ft. yards �_bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes �No <br /> 1995 LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> AP R � This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725 The informa�ion contained in this report is <br /> true to the best of my knowledge. <br /> IXi�� ��3.C'cDGi,A t�'EZT. DRIIJ...I1VG L�)., II�:. �71%� <br /> �' Conhactor Business Na e .� License or Registration No. <br /> i <br /> ;�,. <br /> - Representative Signature Date <br /> LOCFlL COPY H 5 9 4 9 8 T� �`� <br /> Name ol Person Sealing Well or Boring <br /> H601434-01 <br />