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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing Minnesota <br /> Well and Boring H 103501 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township N e Township No. Range No. Section No. Fraction(sm.->Ig.) Date Sealed Date Well or Boring Constructed <br /> y " <br /> Numerical Street Address or Fire Number and City of Well or Boring Location - <br /> r Depth Before Sealing —ft. Original Depth ft. <br /> Show exact loca I n of Mor boring I Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X' -• location, showing propertyIngle Aquifer E] Multiaquifer <br /> lines,roads,and buildings. - <br /> N WELUBORING ❑ Measured �stimated <br /> Vater Supply Well ❑Monit.Well / <br /> ---- --^ ❑ Env.Bore Hole ❑Other ft. P11(elow ❑ above land surface <br /> W --r- -�-- --�-- --�-- E ,�. �1J/ CASING TYPE(S) <br /> - -- -=-- --=-- --=-- „ feel ❑ Plastic ❑Tile ❑Other <br /> Ya mile <br /> CASING <br /> Diameter Depth f Set in oversize hole? Annualar space initially grouted? <br /> pfr r mneie - _ "'"'• _ in.from_S�� to ft. <br /> E]Yes o E] Yes E] No El Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑Yes ❑No ❑ Unknown <br /> Property owner's mailing a dress if different than well oca ion ad ress indicated above. in.from to ft. ❑ Yes ❑ No ❑Yes ❑ No ❑ Unknown <br /> 6033 Cherrywo d Lam, SCREEN/OPEN HOLE / <br /> Mound s NN 5536+ r t Screen from�to � ft. Open Hole from to ft. <br /> OBSTRUCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME 1*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 9"" <br /> Obstruction/Debris/Fill removed? Xes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ❑ Removed of 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 /> tlo Annular Space Exits <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 /> Grouting Material j/t r- to ft. yards t' bags <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 :k- <br /> LICENSED OR REGISTERED CONTRACTOR CERTIPfCATibN <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 /> Q {" <br /> Contractor usiness ame License or gt r No. <br /> q o d epresenta b Signature Date <br /> r <br /> i� 5 0 Name of Person Sealing Well or Boring <br /> LOCAL COPY H 103 <br /> HE-01434-02 10/95R <br />