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Minnesota Well and Boring 7 (� <br /> WELL OR BORING LOCaTiON MINNESOTA DEPARTMENT OF HEALTH Sealing No. H � 1 O�'J <br /> co���v Name ���� WELL AND BORING SEALING RECORD orlW series No.ue Na <br /> Minnesota Statutes.Chapter 103/ <br /> �Leave biank�f not k�own) <br /> Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br /> ,ry or Boring Constructed <br /> C��10 117 �3 16 �i�+,—U(���',q c <br /> Nume�i�cyal Str�ee�t A1.d�,d.�re,�s,s or Fire Number and City of Well or Boring�ocation � ` � <br /> 17L� wlui7 rL. i�1lA. vi(jt]Q� r,aj� DepthBetoreSealing ���/ ft OriginalDepth �`� ft <br /> Show exact location o(well or boring Sketch map of weli or boring Static Water Level �Accurate <br /> �n section grid with��X��. ". location.showing property hnes. <br /> ��-;;- roads.and buildings. ❑Approximate <br /> N <br /> i i i i_ y.. / <br /> -; -;- -;- -� <br /> '--,j, Single Aquifer ❑Multiaquiter —�.�—fL � below above land surtace <br /> i i i i <br /> _i_ _�_ _�_ _i_ CASING TVPE <br /> W i i � i E <br /> � � � i T <br /> -r -�- -r- -r T <br /> i i i i '�e j y+�` Steel ❑Plastic ❑Tile ❑Other <br /> �.� <br /> _i i i i_ �� ' e <br /> i _i_ _i _ _i { �, / I <br /> ,; ! fa <br /> t ._ ...�.�� _ Screen from� to � fl. Open Hole from to ft. <br /> S <br /> N--i m7e--�I OBSTRUCTION/DEBRIS/FILL <br /> - PROPERTY OWNER'S NAME �Obsiruction ❑Debris ❑Fill <br /> Taylor Lauer Constrct�on, Inc. <br /> a i..�.us`iP �.!`i°f_. 4 �ml� <br /> Type of debris/obstruction <br /> Mading Address rf different than property address indicated above. <br /> �-,r-,-� ��t� � Obsiruction/Debris/Fillremoved? Yes ❑No <br /> �_}L i.;ZS � <br /> PUMP <br /> �`ti;�t��li:, ri�t. �`_>±lb <br /> �temoved ❑Not Present ❑ Other �„�J� ��m� <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole7 Annular space ini[ially grouted7 <br /> - If not known,indicate estimated brma�ion log from nearby well or boring. � <br /> � � <br /> Q ��ls �in.from �to � it. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Ves ❑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 /> �No Annular Space Exisis <br /> 'l '� ❑Annular space grouted with�remie pipe <br /> � _ <br /> .�� � ❑Casing Perforation/Removal <br /> i <br /> in.from �o ft. ❑Perforated ❑Removed <br /> in.irom to tt. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> / i <br /> Grouling material�/��/ �����j from � to !!�/ ft. yards ��bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> - from ro tt. yards bags <br /> from to (t. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <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 /> �J�i 4`�.�lJl.if�� ;h�� aX�.t.i.LL�� �.-L'.� 1�.. c:�� �f. <br /> Contractor Business Name License or Registration No. <br /> ....-..%i l� /' ...�- A " �`�,` . C7—�GT3`f � <br /> �� <br /> �aT� t�d epresentabve Sgnature Date <br /> I.00AL C;OPY H 5�O 2 O `I�il� A21tO�OLi <br /> Name ol Person Sealing Well or Boring <br /> ., i H601434-01 <br />