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Minnesota Well and Boring ^ ^ <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H L 8 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Minnesota Statutes.Chapter 1031 or W-series No. <br /> (Leave blank it not known) <br /> Township Name ownship No. Range No. Section No. Fraction ism. Ig.) Date Sealed Approximate Date Well <br /> I ' --j '2 - IQ (l4 4 ' , - :� '-71 or Boring Constructed <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> Depth Before Sealing 1 ft. Original Depth i` `I�� ft. <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level 57,Accurate <br /> in section grid with"X. location,showing property lines. <br /> N roads,and buildings. ElApproximate <br /> single Aquifer ❑Multiaquifer --�ft. below above land surface <br /> t i i t <br /> -t- - - -i- -t- CASING TYPE <br /> W E <br /> t t t t <br /> t t t t Steel ❑Plastic ❑Tile ❑Other <br /> Ll <br /> mile <br /> S Screen from I{>L.. to ft. Open Hole from 10 ft. <br /> 1 mile ► OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME Obstruction ❑Debris ElFill <br /> Type of debris/obstructionL1.* <br /> Mailing Address if different than propill address indicated above. <br /> Obstruction/Debris/Fill removed? Yes ❑No <br /> PUMP <br /> EkRemoved ❑Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> � <br /> infrom to ❑ <br /> c <br /> l\ . �J.IL"ft. Yes Elo ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑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 /> XNo Annular Space Exists <br /> ❑Annular space grouted with trial 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 <br /> Grouting material I i \ - .r. 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 /> /� <br /> ((�� Other unsealed well or boring on property? El Yes Q(No <br /> NOV V <br /> V 3 1.393 LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <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 /> E , U_ _ l l l l <br /> 4 <br /> Contractor Business Name License or Registration No. <br /> r y ' C. <br /> Authorized Representative Signature p Date / <br /> LOCAL COPY H 4 V V 2 V \ <br /> Name o/Person Sealing Well or <br /> Boring <br /> HE-01434-01 <br />