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_ _, ,..-- . , t _ _�« :.::-�._.-_-..;—� � „ e.��� �-,� <br />� � _., , . . . :� <br /> MIELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH M�nnesota Well and Bonng i�-14 7 6 9 3� <br /> WELL AND BORING SEALING RECORD sea''�9"° ,H <br /> Counry Name M�nnesota Unique No. — <br /> ��Y3218�iiA Mmnesota Stafutes,Chapter 7031 or W-series No. � <br /> ILeave Wank�I nut krwwn� <br /> Township Name Township No. Range No Section No. Fracuon�sm.-►Ig.) Date Sealed Date Well or Boring Constmctetl <br /> Urono it7 23 5 ti H 1/�/yQ <br /> Numerical Street Address or Fire Number and Gry of Well or Bonng Loca6on <br /> 35b� �arsl�� �� OrO�Q Dep�hBeforeSealing 14� fl OnginalDepth j'40 � <br /> Show exact loca6on ol N•ell or bonng A ^ Sketch map ol well or bonng AOUIFER(S) STATIC WATER LEVEL <br /> in section gnd with'X'. j\ ) � location, showing property �Single Aywfer ❑ Mul�laqwfer <br /> � V lines,roads,and buildings. <br /> N WELUBORING �Measure0 ❑ Esumated <br /> �Water Supply Well ❑Monit.Well <br /> �,,.�.,.^ ❑ Env.Bore Hole ❑Other _ 4Q fl �bebrv ❑abore yand si�rkaoe <br /> � � � i <br /> W - - -i-- -�-- --�-- E ` CASING TYPE(S) <br /> -�-- ---- -;-- --�-- � �Steel ❑Plastic ❑Tile �Other <br /> i � � � ;�mde ��, <br /> —�- -�-- -�-- --i-- � . '�,. ,----�. CASING <br /> :"�� �_ .� Diameter Depth Set m oversize hole? AnnuaYar�oare rrlia�y goded� <br /> S �� �y <br /> �„�� ! F 4 in.from� to j•3f? R. ❑Yes �No ❑Yes ❑No ❑lMrow�w� <br /> i � <br /> PROPERTV OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑Yes ❑I�b ❑lM°nw� <br /> Property owner's mailirg address if diflerent than wel�location address indicated above. in.from to tt. ❑ Yes ❑No ❑M� ❑� ❑��� <br /> SCREEWOPEN HOLE <br /> Screen from i�b to �4V ft. Open Hole from b ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME <br /> Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑No Obstnctim <br /> WeM owneYs meip addrass N dillerent than propeny owner's atldress inAicated above. Type Of ObstruC�ionS(DeScribe)���,j�t �1� �e r+ <br /> Obstructions removed? [�Yes ❑ No Describe <br /> PUMP <br /> TyPe���i <br /> (iEOlOfi1CAL NATERUL COLOFi HARDNESS OF FROM TO � Removed ❑ Nol Present ❑ Other <br /> FORMATION <br /> B aot krqwn,irWicete eatimated formatbn log hom near�y well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OF1 CASNC AI�BOIE MOLE <br /> � No Annular Space Ezi�s <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing PeAoratioNRertroval <br /> in.from to fl. ❑ �a1ed ❑ Rennred <br /> in.from to ft. ❑ �b� ❑ �nr'ed <br /> Type of perforator <br /> p Omer <br /> GROUTING MATERIAyS) <br /> GroutinqMaterial �'artland fram 1�U to V R ya�ds j b�ys <br /> ��«� �o R � � <br /> norn ro R �ds e�pc <br /> from to R �dc 6� <br /> RENARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes []Wo How msy� <br /> LICENSED OR REGISTEREO CONTAACTOR CERTIFICATION <br /> This well or boring was sealed in accorde�ce wilh Minnesota Rules,Chapter 4725.The iionnion aa�ird"n�is rapoA s <br /> � true to the best of my knowledge. <br /> �t�S t�r�ll �rillin� 27�7� <br /> conrracro.6usirress Nerrre Lisur o.wq'sr�on aa <br /> � " ,�� � .�- _-i`� � ��`��� <br /> AuMorized Representadve Sig�ature <br /> tT��`t�� �C� <br /> LOCAL COPY H 1�f' I �.,J� Neme ol Person SeaN^9 WeM a Bonng <br /> HE-01434-03 �R <br />