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Minnesota Well and Boring 3 6 0 5 8 <br /> we�� oR BORiNG�OCn7ioN MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> �o���Y Name WELL AND BORING SEALING RECORD Mi��esota u�iq�e No <br /> Minnesofa Statutes.Chapter 103/ or W-series No. <br /> �'lE;,t�����1 - � �Leave blank d nol knowm <br /> Township Name Township No. Range No. SecOon Na Fraction(sm. �Ig.) Date Sealed Approximate Date We�l <br /> CxC�� � �� G.� {J� 4 r4 Ia ( .,� 1 �,r� � or Boring Cons�ructed <br /> �'f j �_� <br /> Numencal Street Address or Fire Number and City of Well or Bonng Location <br /> C <br /> '�(�,� � Depth Before Sealing ,���� ft. Original Dep�h � � ft. <br /> �.�Lt� �tn"'?{ 7 -t Q` <br /> Show exact location of well or boring Sketch map of well or bonng StaGc Water Level Accurate <br /> in section grid with��X�. location.showing property hnes, _ <br /> oads.and bwldings. ❑Approximate <br /> N <br /> � � � � <br /> __ _-_ _-_ __ � <br /> 7�+ Single Aquifer ❑Multiaqui�er tt. � below above land surface <br /> i i i i <br /> -'- -� -i- -�- A G TYPE <br /> W i i i i E <br /> � i � � ` <br /> -r -�- -r- -r 1'_._._._.. <br /> i i i i Steel ❑Plastic ❑Tile ❑Other <br /> mile <br /> _� � I �_ � <br /> _ _—_ _i _ _I <br /> / 1' <br /> S - Screen from �` to �� it. Open Hole from to ft. <br /> �--1 mile--►I -. �-� - � F' `'��� OBSTRUCTION/DEBRIS/FILL <br /> ❑Obstruction ❑Debris ❑Fill <br /> PROPERTY OWNER'S NAME <br /> VF+ixk F�,; 1y i;-+-,,.r. < <br /> �'` Type of debris/obstruction �� ��-'�� t'' ������ � ' '�1 <br /> Mailing Address d drf(erent than property address indicated above. <br /> Obsiruction/Debris/Fill removed? es ❑No <br /> PUMP � <br /> ❑Removed Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Se�in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> i <br /> ��� in.from r�� to � tt. ❑Yes �o ❑Yes ❑No ❑Unknown <br /> drift 0 I <br /> in.from to f�. ❑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 /> o Annular Space Exists <br /> nular space grouted with tremie pipe <br /> '--� ❑Casing Perfora�ion/Removal <br /> ' in.from to ft. ❑Perforated ❑Removed <br /> in.from to fl. ❑Perforated ❑Removed <br /> Type of perforator <br /> , <br /> ❑Other <br /> GROUTING MATERIAL <br /> '� ` e <br /> Grou�ing material �\ A--.;,� t.�Y�_.�,�C from �to �"�ft. yards �bags <br /> from to fl. yards bags <br /> REMARKS,SOURCE OF OATA,DIFFICULTIES IN SEALING <br /> from �o ft. yards bags <br /> ��� � ���� �� ��� � from to ft. yards bags -` <br /> 1 be,g Ce�ent <br /> � �� ��~j te UNSEALED WELLS AND BORWGS - <br /> iAli <br /> fp.��� Other unsealed wel�or boring on property? ❑Yes No <br /> Z R� 1�� r� C� C�t �`��t � LICENSED OR REGISTERED CONTRACTOR CERTIFICAT N <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> irue to the best of my knowledge. <br /> !.'t,}I�Y : l�,'�.X_.�.ES �i��.� rl�l.��.waY� l�l�w r �_Ik{..�w !'r J /t: <br /> Contractor Business Name License or Registration No. <br /> f <br /> f;=:=-'=� ./ :-;�"��� t�3 <br /> thori� d Representative Signafure � Date <br /> LOCAL COPY I„I '�,irn i�xelrA <br /> Name ol Person ealing Well or Boring <br /> HE-01434-01 - <br />