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WELL OR BORING LOCATION M71nnl7:a Well and Boring H 29229 <br /> MINNESOTA DEPARTMENT OF HEALTH SealinggNo. <br /> County NameWELL AND BORING SEALING RECORD Minnesota Unique No. <br /> r Minnesota Statutes,Chapter 1031 or W-series No. <br /> 11(,i-) •14 --1 (Leave blank d not known) --— <br /> Township <br /> -- <br /> Township Name Township No. Range No. Section No. Fraction(sm. •1g.) Date Sealed Approximate Date Well <br /> C)f );' I f / <br /> .J I 1 :, <br /> or Boring Constructed <br /> l4 14 4 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> I I : 1 !/j r/1/hi -- -r--, Depth Before Sealing 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 /> roads.and buildings. ❑Approximate <br /> N <br /> i <br /> --� Single Aquifer El Multiaquifer ft. below above land surface <br /> 4 • ->- CASING TYPE <br /> W E <br /> t <br /> -, i Steel 0 Plastic 0 Tile ❑Other <br /> r smile <br /> i <br /> t . <br /> S Screen from -" to ft. Open Hole from to ft. <br /> N--r mile OBSTRUCTION/DEBRIS/FILL <br /> ❑Obstruction ❑Debris 0 Fill <br /> PROPERTY OWNER'S NAME <br /> J- ?r' (' 1/, — <br /> Type of debris/obstruction <br /> Mailing Address if different than property address indicated above. <br /> Obstruction/Debris/Fill removed? ❑Yes l'No <br /> PUMP <br /> q Removed 0 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 /> 4f in.from (_) to • ' ft. ❑Yes 0 No 0 Yes 0 No 0 Unknown <br /> in.from to ft. El Yes 0 No 0 Yes 0 No 0 Unknown <br /> in.from to ft. El Yes El No ❑Yes 0 No 0 Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> [3(No Annular Space Exists <br /> 0 Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated ❑Removed <br /> Type of perforator _ <br /> El Other <br /> GROUTING MATERIAL '',��; II <br /> Grouting material O- • 1 i• (ifrom -- ' to h ft. I.1cf1yards ( r! 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? y(Yes 0 No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> I <br /> 1 This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> . r ,� 1 4 true to the best of my knowledge. <br /> CorYtractor Business Name License or Registration No. <br /> . 1 <br /> Authorized Representative Signature f',:.-: Date <br /> LOCAL COPY H 29229 :.---, <br /> .l229f r , ,, <br /> Name of Person Sea,fmg Well or Boring <br /> HE-01434-01 - -- – <br />