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Minnesota Well and Boring <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 41370 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> � Minnesota Statutes, Chapter 103/ or W-series No. <br /> =1eY�^� in (Leave blank,f not ku—nl <br /> Township Name Township No. Range No. Section No. Fraction(sm. Ig.) Date Sealed Approximate Date Well <br /> or Boring Constructed <br /> a a t <br /> Numerical Street Address or Fire Number and City of Well or Boring Location _ t <br /> �. _ Depth Before Sealing ��� ft. Original Depth � �� it <br /> " . <br /> t <br /> Show exact location of well or boring Sketch map of well or onn9 Static Water Level XAccurate <br /> in section grid with"X`. location,showing propert lines. <br /> roads.and buil ings. ❑Approximate <br /> N <br /> Single Aquifer ❑Multiaquifer fL below above land styrface <br /> CASING TYPE <br /> W E <br /> mite _. Steel ❑Plastic ❑Tile ❑Other <br /> S �- Screen from to .� it Open Hole from to ft. <br /> N I mire -►I 3 OBSTRUCTION/DEBRIS/FILL _ <br /> PROPERTY OWNER'S NAME ;KObsiructlon ❑Debris ❑Fill <br /> Mi ke J�,fflll <br /> �"� 6���"� <br /> Type of debris/obstruction Ok ���� � l�lY'�� l=�=�• p- �f�� <br /> Mailing Address If different than property address indicated above. <br /> 7.,,., Obstruction/Debris/Fill removed? es El No `� <br /> �'uGt-t Hare PUMP <br /> J <br /> 'I"i Fair[ Lake Stxe..e+- <br /> ❑Removed Not Present ❑ Other _. <br /> 1 :i7 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 knownindicate estimated formation log from nearby well or boring. t � <br /> 1 <br /> drift 0 1 S- in.from to ft ❑Yes ;fo ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> ,,M----,E//THOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �qNo Annular Space Exists <br /> //❑``Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to IL ❑Perforated ❑Removed <br /> MType of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> Grouting material r .Z1'd 7 LX f7rt 4,"`k .ffrom _40� 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 /> Other unsealed well or boring on property? ❑Yes XN. <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 /> Don 5tc Bola well Drilling Co. , Inc Z71,72 <br /> Contractor Business Name License or Registration No. <br /> ArGThoozed Rer � •' <br /> presentative Slgnaturrf ate <br /> LOCAL.COPYI I Jim Antoris )n <br /> Name of Person Sealing Well or Boring <br /> HE-01434-01 - <br /> --, <br />