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Minnesota Well and Boring <br /> MINNESOTA DEPARTMENT OF HEALTH Sealing No H 7 0P,O <br /> WELL OR BORING LOCATION 1 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> �f Minnesota Statutes. Chapter 103/ or W-senes No <br /> 1.1.:.-.11.1 ICI'1 11 p (Leave blank A nol known) <br /> Township Name Township No Range No Section No Fraction Ism •Ig I Date Sealed Approximate Date Well <br /> ,._.r..;-.t <br /> r .f.t 1 <br /> i e't4. , 71C ''d or Boring Constructed <br /> Numerical Street Address or Fire Number and City of Well or Boring Location / //y�f <br /> r_.. :1 =..J'r. t.,r(.t',,f ,ti i. Depth Before Sealing <br /> 14/7–‘;.7 ft Original Depth • ! 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 /> r and buildings ❑Approximate <br /> N wa►}V* 7P" . <br /> *Single Yl Single Aquifer ❑Multiaquifer // Zri ftX below above land surface <br /> A _i - Jam,' CASING TYPE <br /> W ; E <br /> 1-, - - j4 Steel ❑Plastic ❑Tile ❑Other . <br /> I . <br /> 'f <br /> S Screen from (/88 10 /�` ft. Open Hole from to h a <br /> / <br /> HI-- i r''''— * t, - OBSTRUCTION/DEBRIS/FILL <br /> {{ <br /> \ xObslruclion ❑Debris ❑Fill <br /> PROPERTY OWNER'S NAME - - rY <br /> eater Althea CaKvany � y *•. <br /> Type //LYItf./r! 1 j i ' Q /--^ O // <br /> T e of debris/obstruction ->:' <br /> Mailing Address if different than properly address indicated above <br /> Obstruction/Debris/Fill removed? ❑No <br /> 14140 .78th,-$t. <br /> Ifttit, . PUMP ii <br /> ' d Prairie"'**.5534', <br /> Removed ❑Not Present ❑ Other 56PL)/ ?P <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ' <br /> FORMATION <br /> P. <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 /> infrom �toLea' ft ❑Yes �No ❑Yes ❑No 111 Unknown "1 <br /> -) <» Si <br /> infrom 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 /> No Annular Space Exists '1 <br /> ❑Annular space grouted with tremie pipe '? <br /> ❑Casing Perforation/Removal <br /> ,a <br /> infrom to ft. ❑Perforated ❑Removed <br /> infrom to ft. ❑Perforated ❑Removed ,!..4: <br /> :i';3 <br /> Type of perforator ' <br /> `r <br /> ❑Other <br /> GROUTING MATERIAL <br /> .6'0- . <br /> Grouting material from _el_to ft. yards 162f•- <br /> bags <br /> , <br /> 50 <br /> .41 <br /> from to ft yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ftyards bags `'-', <br /> from to ftyards bags `'i <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑YesJo <br /> .'S <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. 13 <br /> .v; <br /> „PM- i`}iV A WELL DR1 T.mG CO..,.{:C. 27172 <br /> Contractor Business Name License or Registration No 1 fd' <br /> 4resen alive Sig Date a <br /> HName of Person Sealing Well or Boring <br /> HE-01434-01 al <br />