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Minnesota Well and Boring WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No H 65389 County Name WELL AND BORING SEALING RECORD Minnesota Unique No. 11 Minnesota Statutes.Chapter 1031 or W-senes No. i 'C LF. n (Leave blank it nor known) Township Name Township No Range No Section No Fraction Ism .Ig I Date Sealed Approximate Date Well r or Boring Constructed i14 i14 i14 Numerical Street Address or Fire Number and City of Well or Boring Location f Depth Before Sealing ft. Original Depth ( J ft Show exact location of well or boring Sketch map of well or boring Static Water Level ❑Accurate in section grid with..X.. location.showing properly lines. roads,and buildings ❑Approximate ❑Multia ester t J S ft below above land surface I I U, QSingle Aquifer q CASING TYPE i i i/{ ❑Steel 19 Plastic El Tile El Other mile fP x Screen from to a If Open Hole from to ft S mile OBSTRUCTION/DEBRIS/FILL Obstruction ElDebris ❑Fill PROPERTY OWNER'S NAME ti t, Type of debris/obstruction Li 0;ti Mailing Address if different than properly address indicated above. Obstruction/Debris/Fill removed? KYes 0N PUMP Gr i11/ti.►` LARemoved ❑Not Present ❑ Other CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depth Set in oversize hole? Annular space initially grouted If not known.Indicate estimated formation log from nearby well or boring. A# ( in.from to 'fit r If ❑Yes JKNo DO Yes ❑No ❑Unknown 'Y in.from to It. ❑Yes ❑No ❑Yes ❑No ❑Unknown infrom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: a No Annular Space Exists Annular space grouted with tremie pipe ❑Casing Perforation/Removal infrom to ft. ❑Perforated ❑Removed in.from to It. ❑Perforated ❑Removed Type of perforator ❑Other GROUTING MATERIAL rr y Grouting material �` -" ✓�- tC from r_1 to Ityards l7 bags from to It yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING from to Ifyards bags - from to f1yards bags UNSEALED WELLS AND BORINGS 1,,;, Other unsealed well or boring on property? (R Yes ❑No LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is - true to the best of my knowledge. Contractor Business Name License or Registration No. Authorized Representative Signature Date C 6,93811 Name of Person Sealing Well or Boring HE-01434-01