Laserfiche WebLink
Minnesota Well and Boring �� � <br /> WELL OR BOR�NG LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> �o„�,,�,ame WELL AND BORING SEALING RECORD^^���eso�a u��q�e No. <br /> fi Mmnesota Sfatutes.Chapter 703/ or W-senes No. <br /> ILeave Dlank il nol knownl <br /> T .ship Name Township No Range No Sechon No Fracbon(sm. I � Da�e.Seale ' ..� Approximate Date Well <br /> ,_ j i� t. �-•' /% . i or Bonng Construcled <br /> �-; -,� 7 J ��,���,4 �, , � J � ; � <br /> Numencal Sireet Address or Fire Numbei and Gty, Well or Bonng Lcealion �, � <br /> " F� Depth Before Seal�ng �%�"�'� fl. Onginal Depih ft. <br /> C.:.t/ . 7" r� <br /> Show exact Iceatan of well or bonng Sketch map ot well or bonng Stalic Water Level Q�Accurete <br /> �n section gnd wdh��X" loca6on.showing property lines. <br /> roads.and bwldings. ❑Approximate <br /> N � <br /> � I <br /> � � �Smgle Aquder ❑Multiaqurfer ' '� fl. below above land suAace <br /> i <br /> _�_ - -i- � CASING TYPE • <br /> W -- -� E <br /> � -� r i � ,�v.Steel ❑Plashc ❑Tile ❑Other <br /> mr�e <br /> i i <br /> i i i � � �1 C `7 <br /> S Screen irom to ft Open Hole from�-= lo��� '0��� tl <br /> � �'"'k� OBSTRUCTION/DEBRIS/FILL <br /> ❑Obstruc�ion �❑Debns ❑FII <br /> PROPEA'fk OWNER'S N <br /> Type of debns/obsiruchon <br /> Mailing Addre ddferent ihan property address indicaled above <br /> ObstrucLon/Debns/Fill removed7 ❑Yes ❑No <br /> PUMP <br /> Removed ❑Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � <br /> FORMATION <br /> Diameter Depth Se�m oversize hole? Annular space irntially grouted� <br /> tf not known,indicale esUmated formahon log irom nearby well or bormg. .,,....,. <br /> / 1 a <br /> in.irom r "' to�-�- � ;- ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to fl. ❑Ves ❑No ❑Yes ❑No ❑Unknown - <br /> in.from �o 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 Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to fl. ❑PeAorated ❑Removed <br /> in.irom ro fl. ❑PeAorated ❑Removed <br /> Type of peAorator <br /> ❑Other <br /> GROUTING MATERIAL <br /> �...�}��, � � � � <br /> Groufingmaterial "" �`r'l.�C/`�� irom ' � to t/ ft. yards bags <br /> from to fl. yartls bags <br /> REMARKS.SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes �"No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> J�� � O ��� This well o�boring was sealed in accordance with Minnesota Rules,Chapter 4725 The inbrma6on contained in Ihis repon is <br /> Irue to iheb'est of my kn�ledge. ,� ,. <br /> .3 1� ^ <br /> . - !�f ' � .� I i <br /> .._ <br /> � , ! ,., E <br /> .� •} ^ ;:.,.,:�.n r r-. {� . .�, <.-' / <br /> ConhactorBusrness Name f L�cense or Registrafron�No. <br /> � ' f <br /> �dr, '/ . /"_..'J. <br /> �'` ; � <br /> -�; <br /> Aulhonze � ep`r`esentative Signafure � f�� � Date <br /> ; ,' � <br /> ��� F t r'�..I f /, ., �"/.r'�-Y�G's•t_--.. <br /> ��f���Wj n Name o�Person Sealrng Well o�Bonng <br /> HE-01434�0� <br />