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Minnesota Well and Boring u <br /> WELL OR BORING LOCATION MINH <br /> NESOTA DEPARTMENT OF HEALTH Sealing No. 40262 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> iknnl )ln Minnesota Statutes.Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Townshi No. Range No. Section No. Fraction Ism. -Ig.) Date Sealed Approximate Date Well <br /> CIrC 20 & LJ 24 t 0 {rt or Boring Constructed <br /> to la to <br /> Numerical Street Address or <br /> Fire Number and City of Well or Boring Location c 6 q r <br /> 2JGGGo Watertown own RoadO Croon �. 553!.& Depth Before Sealing �`�1 ft. Original Depth y ft. <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level Accurate <br /> in section grid with X. - location.showing property lines, .. <br /> road an buildings. ❑Approximate <br /> N <br /> r <br /> I I I I <br /> Single Aquifer ❑Multiaquifer ft below above land surface <br /> CASING TYPE <br /> W E <br /> -r -�- -r- -r <br /> t ) Steel ❑Plastic ❑Tile ❑Other <br /> b mde <br /> Screen from to ft. Open Hole from to ft. <br /> S <br /> I mile -D OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME - <br /> El Obstruction El Debris ❑Fill <br /> & ftimal Marti,! <br /> Type of debris/obstruction G <br /> Mailing Address if different than property address indicated above. <br /> Obstruction/Debris/Fill removed? Yes ❑No <br /> ' .. 011111m,,iiii ... PUMP <br /> ❑Removed 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 /> in.from to �- ft. ❑Yes L]J�lo El Yes EJ No El Unknown <br /> drift <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 /> X. <br /> 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 ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL 1 <br /> Grouting material ``V'd fromto /.1 / ft. yards bags <br /> from to ftyards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> -- from to ft. yards bags <br /> Grouted 4" well 90' <br /> 8 bags C1L'Tlt from to ft. yards bags <br /> d{. <br /> 10 lbs bentonite ., UNSEALED WELLS AND BORINGS <br /> ;yen labor, rig & ;� C g property? <br /> Other unsealed well or born on ❑Yes o <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFI ATION <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 /> i,; '� WE.L R1t�L NG (X,. INC. 2717� <br /> Contractor Business Name License or Registration No. <br /> &-11-93 <br /> Aut- hod Represen ative Signature Date <br /> LOCAL COPY Fi tim 141" <br /> Name o/Person Sealing Well or Boring <br /> HE-01434-01 '-"""*""• <br />