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Minnesota Well and Boring <br />WELL OR WMNGLOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No 1H 7 O <br />County Name -- - WELL AND BORING SEALING RECORD Minnesota Unique No --- <br />Minnesota Statutes. Chapter 1031 or Wsenes No <br />i�nnet;in ,IP•rlUNrV,.r,¢M.,.ri.., �---------- -- ----- <br />Township Name Township No Range No Soclwn No Fraction Ism • Ig I Dale Sealed Approximate Date Well <br />Li t l is 11 ` (. J ' ' ' 1 — -'A' .. Gq , or Boring ConstructedM <br />Nhanonral Street Address or Fire Number <br />n <br />and City of Well or Bog Localion <br />2 1 t' C011ill LWjl,-t' ] Xr,(j J.cilZl` a N4.- - ., . Depth Before Sealing II Original Depth <br />Slow esad location of well or boiling Sketch map of well or toting SlaW Water Level Accurate <br />in fiction god with X leu cion showing properly lines <br />N roads and buildings ❑ Appro■imale <br />Single AiT,rder ❑ Multiartuder _�` n habw above land surface <br />WING TYPE <br />W <br />1 1 1 1 • /f Ufa <br />1 1 1 1 ,•rte y `•I,.i i_1 Pla5tic ❑ Tile U Olhei <br />�- - <br />!T!1+1 -1 t� <br />Scree, from — .e -- If Open Hole from to it <br />1� S <br />OSSTRUCTIOWDEERIEIFILL <br />Obstruction ❑ Debris ❑ Fill <br />PROPERTY OWNER'S NAME <br />P•�I'�'7 i. '.�t;T-,r .•til 1 <br />__----— - -- - - Type of debris obstruction <br />Mailinil Address if different than properly address indicated above <br />ODstnictwnrDabnsFsl removod' Vee ❑ No <br />PUMP <br />❑ Removed ftl Preset" ❑ Other <br />CASING <br />Diameter Depth Set in oversize holey Annular space initially grouted' <br />in from � to — _� ft El`,y" Yes t�Nu ❑Yes El C1Unkrw <br />in from to _.— It ❑ Yes El No ❑ Yes ❑ No ❑ Unkno <br />It G re, ❑ No ❑ Yes ❑ No ❑ Unkno <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OF <br />FORMATION <br />FROM <br />--- <br />TO <br />- <br />It not knownindicate estimated formation log from nearby well or twang <br />1 <br />-- - - - <br />USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS. OR CASING AND SORF MOLE: <br />u Annula, Space E.isls <br />nnular space grouted with tremae pipe <br />asing PedooatiorvRemnval <br />f <br />REMARKS. SOURCE OF DATA, DIFFICULTIES IN SEALING <br />Grt Lt Well 7" <br />L i q's corelnt. <br />a ljl*;. k3 %ni- xIl to <br />L Wr.E Ji sr t;iE Rite ailnor"t Cb,en't (07rut F).l; <br />H 46706 <br />in from to it ❑ PoAwaled ❑ Removed <br />in from to it ❑ Perforated ❑ Removed <br />Type of perforator <br />❑ Other <br />GROUTING MATERIAL <br />Groutingmatenal � t. t Brom to <br />born . to _ 11 yards <br />from _ to if yards <br />from to if yards --_ bags <br />UNSEALED WELLS AND BORINGS <br />Othei unsealed well w miring on property'/ ❑ YesNo <br />LICENSED OR REGISTERED CONTRACTOR CFR 1111-KATIbIll <br />This well or twang was sealed in accordance with Minnesota Rules Chapter 4715 The ,nftomalion corlained ,e th,S leprid is <br />true to the txsl of ray knowkWQTa <br />iN•_!L1JN6 l,_ . i.t'. <br />Ccwtrachm Busmeas Name L icense w No -- <br />""I've S"b" <br />13. =.rte Mkt , <br />Alanre 01 Peistr, Seating WMl ur Swing <br />uale <br />