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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL AND BORING SEALING RECORD Sealing H 112974 <br /> County Name Minnesota <br /> Unique No. <br /> I3emepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township NameTownship No. Range No. Section No. Fraction(sm.->Ig.) Date Sealed Date Well or Boring Constructed <br /> Clrcr►c� 1 t t 23 31 0 <=(� <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> i <br /> 320 Ttri1l=i R(}�d (,r(')ll Mi. Depth Before Sealing —ft. Original Depth 14oz– ft. <br /> Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, shpwing propertyingle Aquifer E] Multiaquifer <br /> linac rnarlc Andbu�dings. <br /> N WELL/BORING )<vAeasured ❑ Estimated <br /> : E Water Supply Well E]Monit.Well <br /> ` ❑ Env.Bore Hole ❑Other ft. below ❑ above land surface <br /> --r- -�-- --�-- --�-- <br /> W E ,-e J CASING TYPE(S) <br /> r � � �lle I Steel E] Plastic E]Tile E] Other <br /> -�-- - - -i-- - it CASING <br /> j d f <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> pIts <br /> I 1 milef.We , in.from U to ❑ Yes No ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAMEButch Ze3..11lik in.from to ft. ElYes ❑�No E] Yes E] No E] Unknown <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> Screen from to ft. Open Hole from to ft. <br /> OBSTRUCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME <br /> Obstruction ❑ Debris ❑ Fill ❑ No Obrstructiofn/.�9 <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill <br /> Obstruction/Debris/Fill removed? XYes ❑ No <br /> PUMP <br /> Type :5 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO }ia Removed ❑ Not 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 /> )<No Annular Space Exits <br /> r_.. <br /> ❑ Annular space grouted with tremie pipe <br /> l.j ❑ 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 -f om 4— to ft. yards ,5p 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 No _ <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 /> rjN ODU a WELL <br /> iRT2aNG W. 11C. t <br /> Contractor Business Name License or Registration No. <br /> rr <br /> „AfithoR presentaGv�" rgnature Date <br /> LOCAL COPY H <br /> 2974 Name of Person Sealing Well or Boring <br /> HE-01434-02 10/95R <br />