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Minnesota Well and Boring 419 8 � <br /> � WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> �o���Y Name WELL AND BORING SEALING RECORD M���esota u��q�e No. <br /> Minnesota Statutes. Chapter 1031 or W-series No. <br />^ �-��,N N lLeave blank if not known) <br /> Township Name Township No. Range No. Sechon No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br /> or Boring Construc�ed 1 <br /> ,,, „���, ',4 'r4 ',4 1 — � — �? s / � 5 C% <br /> Numencal SVeet Address or Fire Number and Ciry of Well or Boring Location \ <br /> ` / /��y � , {� ; Depth Be(ore Sealing ? � a ft. Onginal Depth _ � ? �+�- ft. <br /> � t n� � vc „� <br /> Show exact location of welt or boring Sketch map of well or bonng Static Water Levet �Accurate <br /> m section grid with�-X". location.showing property lines. <br /> roads.and bwldings. ❑Approximate <br /> N <br /> � � i � <br /> I I I I '�(y <br /> � Single Aqulfer ❑Multiaquifer fl- �— below above land surtace <br /> i i i i �� <br /> _i_ _�_ _i_ _i_ CASING TVPE <br /> W i i i i E <br /> � � i � <br /> -r -�- -r- -r <br /> i i i i � �1) ��'- S�eel ❑PlasGc ❑Tile ❑O�her <br /> :o mile \ ..--`� � <br /> _i i i i_ I al 1 <br /> _ _ _ ___ _ 1 ,�..._+ <br /> � ��,� _ r �,�� �.�; Screen from to fL Open Hole from to It. <br /> �---t mi�e—� � OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME �Obs�ruction ❑Debris ❑Fill <br /> �� �� �� <br /> �� ����� ' � Type of debris/obsiruction ' ���..T�'� � � ����-' '� � <br /> � Mailing Address rf different ihan property address indicated above. <br /> Obstruction/Debris/Fill removed? Yes ❑No <br />.. .r-. P�� PUMP <br /> ❑Removed 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 /> ti � <br /> A ' � �in.irom �✓ to � fL ❑Yes �No ❑Yes ❑No �Unknown <br /> lU <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.irom —to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> - �No Annular Space Exisis <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to fl. ❑Perforated ❑Removed <br /> REType of perforator <br /> 2 lgg ❑Other <br /> GROUTING MATERIAL <br /> 1 <br /> Grouting material �r_ ' -'� �� from '--1 to ��� � fl. yards �..,L bags <br />" �,._ � � ; <br /> " - � � from to fl. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> �t `. <br /> ��`� �� - , h-�, <br /> .� from to ft. yards bags <br /> '` UNSEALED WELLS AND BORINGS <br /> n � <br /> ' ��J,..,t-�.Y-1 +-.i`;�/:j_ �C;(��''� , O�her unsealed well or boring on property7 ❑Yes No <br /> 1 <br /> � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chap[er 4725.The information contained in ihis report is <br /> true to the best of my knowledge. <br /> i.;� 1�� ij � ? a �} `t <br /> Contractor Business Name License or Registration No. <br /> �;' ;�,/� f �, `-.�� � � "�- �:_� ^� <br /> , l <br /> Authorized Ffepresentative Signature Date <br /> f <br /> � <br /> H 419 8 5 j �� < :. , �` � <-,�� ; �- �-, �, <br /> �OCALCGFY <br /> Name ol Person Sealing Well or Boring <br /> ���� H601434-01 <br />