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�> ' WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H � 2 3� 2 5 County Name WELL AND BORING SEALING RECORD Menn�esoNa Unique No. } � p�=,�,:; � r2 Minnesota Statutes,Chapter 1031 or W-series No. (Leave blank If not known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed ��L� �.�.� _� � J iMi:� �i� 'b �f..a`'�. at'� t �.�c1`' '�t"�'�f}F `'. Numerical Street Address or Fire Number and Ciry of Well or Boring Location 1�F !k t •_3��#`� �;�°=7��t��'' f�ks�t� ��! DepthBeforeSealing � � �� tt. OriginalDepth �� ft. Show exact location of well or boring Sketch map of well or boring A UIFER(S) - STATIC WATER LEVEL in section grid with"X". � location, showing property Single Aquifer ❑ Multiaquifer lines,roads,and buildings. N WELUBORING [�Xvleasu�ed ❑ Estimated � � ��Water Supply Well ❑Monit.Well 4U _ _Y_ _ __ __l__ � ❑ Env.Bore Hole ❑Other ft. �below ❑ above land surface —�- -�-- -;-- --i-- W E t�'1 k^^"^'�] CASINGTYPE(S) � � � � � �nil � -;-- -;-- -�-- --�-- � �� Steel ❑ Plastic ❑Tile �Other Y.mile - -�-- -�-- --�-- � . CASING Diameter Depth � Set in oversiz�e7 Annualar space initially grouted? S �J� �lh—i m��e--q� in.from �} to � � ft. ❑ Yes No ❑Yes ❑No ❑ Unknown I PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown Ai�t� 4��3 ,�i}?.I:E V�R�'�°E�U Property owner's mailing address if ditterent than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑Yes ❑No ❑ Unknown �,.3�� E�ISIa�UN �Ak�C JZI) SCREEWOPENHOLE .��}� � �TJ�y� Screen trom �''� to � 7� ft. Open Hole from to ft. OBSTRUCTIO WDEBRIS/FILL WELL OWNER'S NAME ,�� ❑ Obstruction ❑ Debris ❑ Fill �NoObstruction Well owner's mailing address if diiferent than properry owners address indicated above. Type of Obstruction/Debris/Fill ObstructioNDebris/Fill removed? ❑ Yes ❑ No PUMP �,�!k3 Type GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ❑ Not Present ❑ Other FORMATION It not known,indicate eslimateG formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �)�`�' (:t c�� (f�{��' � ��y r,p�No Annular Space Exits T'" ❑ Annular space grouted with tremie pipe F SNF. :iAN€) GRAY ":�i �C) ❑ Casing PeAoration/Removal F-.;..��'4. J��}!.� F��.�� 1.�.�,. in.from �o n. ❑ Perforated ❑ Removed ��T ��Y ��Y ��x�-� in.from to ft. ❑ PeAorated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) i't?IK`�'I,ANl� � ";� :'s(,�[��` ,'� Grouting Material from to ft. yards bags from to ft. yards bags from to ft. yards bags from to__ ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS �.i�.U1..��.s� N��1�"�; ;F1?'%�% �'t){�`�'1"i ��R�". � �therunsealedwellorboringonproperty? ❑ Yes � No �fIA��'L',R LL'V�L 1.N �U.�UV� �L.LL: �O f UCENSED OR REGISTERED CONTRACTOR CERTIFICATION �..s�1�`��'. �:��'�� Le�'1V�J. TA��N: �.Q'-'��" f. This well or bonng was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is t.,, � �,l true to the best of my knowledge. t�<.l�_ �ti�;t�tA1Lf? & 7C)t�iS, INC: . 7#.t�'� '� Conhactor Business Name License or RegistreNon No. . �:.as -. , . .�` �� ' ��f��fj'? .. � _ Authonzed Representative Signature 1 Date n.-�- ` �:�;� �' �� P��E �� R�' .. � . ��:�._ �� :�s,,��:��t;.�zL�:.sr�fx�:v�N �a�� LOCAL COPY H 12 3 3 2 5 Name ol Person Sealing Well or Bonng HE-01434-02 10/95R