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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring —� <br /> Sealing No. H 14441 <br /> � <br /> Cou,Tm� WELL AND BORING SEALING RECORD Minnesota Unique No <br /> K(n{ Minnesota Statutes,Chapter 1031 or W-senes No. <br /> ka4 (Leave blank a not known) <br /> Tgta(tship Name Township No. Range No. Section No. Fr eon(sm.--k Ig.) Date Sealed Date Well or Boring Constructed <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> r <br /> J' Depth Before Sealing 11 - ft. Original Depth ft <br /> Show exall location of well or boring etch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with-X'. location, showing property ❑Single Aquifer ❑ Muleaquder <br /> lines,roads,and buildings. <br /> N WELUBORING ❑'Measured ❑ Estimated <br /> ❑Water Supply Well ❑Montt.Well <br /> E] Env Bore Hole [_1 Other ft ❑below ❑ above land surface <br /> W --r --t-- -­-- --­`-- E '• - CASING TYPE(S) <br /> --�- - <br /> ------------ Steel ❑ Plastic ❑Tile ❑Other <br /> mile <br /> _ti _ CASING <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> S �. <br /> in.from ,�_ to tt. ❑ Yes [3,No ❑ Yes ❑No ❑ Unknown <br /> PROPERTY bWNER'S NAME- in.from to It ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Property or6ner's mailing address 0 /iiteretx'th n e o lion address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑UNcnown <br /> SCREEN/OPEN HOLE <br /> Screen from to ft. Open Hole from to tt. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Dr0 <br /> E] p Pipe p E] Check Valve(s) El Debris E] Fill ❑ No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) <br /> Obstructions removed? ❑ Yes ❑ No Describe <br /> PUMP f <br /> Type -.y,,y,,C'' <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO [:] Removed El Not Present El Other FORMATION <br /> It 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 /> Q No 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 tt. ❑ Perforated ❑ Redwireb <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIALS) <br /> Grouting Material _ from to ft- yards bags <br /> from to ftyards bags <br /> from to tt. yards begs <br /> from to ft. yards pegs <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes ❑No How many? <br /> 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 /> Contractor Business alne`' /Licensol Regls6at ion Pio. <br /> Authorized Repre"ntafi&Signature'' J , Dab <br /> f , <br /> H Name qt PersowSea&-4 W6N or Bonng," �-d--'�.- <br /> LOCAL COPY 14 <br /> HE-0143403 2/97 R <br />