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i <br /> Minnesota Well and Boring <br /> wELL oR eoaw��oCnTioN MINNESOTA DEPARTMENT OF HEALTH Sealing No H 121718 <br /> �����YName WELL AND BORING SEALING RECORD M���eso�a u��q�e No <br /> � Mrnnesota Statutes. Chapter 103/ or W-series No. <br /> �� �4✓' Il F=tvf blank i�nol known� <br /> Township Name Township No Range No. Section No Fraction�sm. �Ig.) Date Sealed Approximate Date Well � <br /> � �� _, � '" or Bonng Gons�ructed J � ..,.� <br /> (�;:� ,�, �„ �,., �„ 1 d� � _ <br /> Numencal Street Atldress or Rre Number and City ol Well or Borng Localion .� , / � ( <br /> � +`� � � ��`...i,. . � , ;"� -.�- Dep�h Before Sea6ng � "� f�. Original Depth � � �� ft <br /> Show exact location ol well or bonng Sketch map of well or boring Static Wa�er Level �Accurate <br /> in sedion gnd wdh�X�� location.showing propeny hnes. <br /> N roads.and bwldings ❑Approximate <br /> I <br /> -;- -;- -;- -;- t � �,)� �� �1 � �� � X <br /> � i �ngle Aquifer ❑Multiaqwfer ft. below above land surtace <br /> i i i i *i <br /> W i i � i E rk� CASING TYPE <br /> � � ..i <br /> i i i i � <br /> -- -�- -r- -r � J,� ,�( <br /> i � i i r L�TS�eel ❑Plashc ❑Tile ❑Other <br /> m�ie s ' t <br /> _ ! !_ _�_ � _ 't <br /> �_ _ _ _ _ <br /> S . Screen from to ft. Open Hole from to ft. <br /> ���mile--�I �. OBSTRUCTION/DEBRIS/FILL <br />� �Obs�ruc�ion ❑Debns ❑Fill <br /> PROPERTY OWNER'S NAME <br /> _�, , ; � � j . i � r <br /> Type of debns/obstruclion <br /> Mading Address d ddferent ihan property addre�ss indicated above. <br /> Obstruchon;Debris:Fill removed7 �Yes ❑No <br /> PUMP <br /> \. <br /> �Removed ❑Not Present ❑ Other <br /> CASING <br />��- GEOLOGICAL MATERIAL COLOFI HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted7 <br /> I(not known.indiwte estimated formahon log fmm�earby well or boring. <br /> ��� � in.Irom � to � � � tL ❑Yes L7No ❑Yes ❑No �Unknown <br /> in.trom !o 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 pND BORE HOLE: <br /> �`'No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casmg Perforalion/Removal <br /> in.from �o fL ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> { r �'` <br /> Grouting material ` �� � � , irom ro � � ���� ft. yards `� bags <br /> from to ft. yards bags - <br /> REMARKS,SOURCE OF DATA.DIFFICULTIES IN SEALING <br /> � from to ft. yards bags ,� <br /> \ �� . �'� t <br /> from to ft. yards bags � <br /> � ��'�._ UNSEAIED WELLS AND BORINGS y...;: . ., �-I � <br /> �. � Other unsealed well or bormg on property? ,[Y Yes ❑No 1,•-.:- � �� <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules.Chapter 4725.The in(ormation contained in ihis report is � <br /> � true to the best of my knowledge. <br /> �/r � � l� C' � �°1,e..�j �/ <br /> Contractor Business N�rne License or Registration No. <br /> ..� �.,ti L,��_�� � � •- '_, . <br /> �� Authorized Re esentafive Signature Date <br /> LOCAL COPY A/ � ' ' � �V � � � , J � <br /> . � 1 f�1 7�8 Name ol Person Sealing Well or Boring <br /> HE-01434-01 .. <br />