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71irlinlA Well and Boring 2 9 2 2 8 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH SealinggNo. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> �) Minnesota Statutes.Chapter 1031 or W-series No. <br /> 1 ' r ,.,-?.'7) r'y (Leave blank I not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm. •Ig.) Date Sealed Approximate Date Well <br /> C_ i•-: Y '1 1 _ -., or Boring Constructed <br /> / d 114 il4 1/4 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> / r; <br /> J 1 (-A-4,1 ti„.. 5.1. j / t Depth Before Sealing �%�l' - ft. Original Depth It. <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. EkApproximate <br /> N <br /> 1 <br /> ---- <br /> 4 CI Aquifer Multiaquifer /'� <br /> Ift. X- below above land surface <br /> 1 <br /> 4, CASING TYPE <br /> W ; I • <br /> 1 <br /> r <br /> 1 (it Steel CI Plastic ❑Tile 0 Other <br /> 1 • x mile <br /> S Screen from ' -� to ' ft. Open Hole from to ft. <br /> N--1 mile-NH OBSTRUCTION/DEBRIS/FILL <br /> ❑.Obstruction ❑Debris ❑Fill <br /> PROPERTY OWNER'S NAME <br /> t <br /> j-()/ . C{ '/ ><,,,s^ <br /> J Type of debris/obstruction <br /> Mailing Address if different than property address indicated above. T5‘,< <br /> No <br /> removed? CI Yes u/No <br /> PUMP \ <br /> ❑Removed ®,.,Not Present 0 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 0 No 0 Yes ❑No 0 Unknown <br /> in.from to ft. ❑Yes 0 No ❑Yes 0 No 0 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 /> tto Annular Space Exists <br /> ❑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 /> ❑Other <br /> GROUTING MATERIAL <br /> Grouting material from .r` T l to ' ft. '' yards . . bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> , 7 <br /> - ?j j , / from to ft. yards bags <br /> from to ft. yards bags <br /> i UNSEALED WELLS AND BORINGS <br /> 1 Other unsealed well or boring on property? E'Yes 0 No <br /> 1)� LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> • <br /> I 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 /> 1 1 <br /> • Contractor Business Name .f1cepse or Registration No. <br /> �, fs• <br /> Authorized Representative Signature ' _ Date <br /> • <br /> LOCAL COPY H 29228 <br /> Name of Person Sealing Well or Boring <br /> ' HE-01434-01 • <br />