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Minnesota Well and Boring <br /> '' WEIL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 4 2 9 0 5 <br /> �o���Y Name WELL AND BORING SEALING RECORD M���esota u��q�e No , . <br /> �p� Minnesota Statutes.Chapter 103/ or W-series No. <br /> fLeave blank il nol knownl <br /> �-. Township Name Township No. Range No. SecUon No. Fraction(sm. �Ig.� Date Sealed Approximate Date Well <br /> � ��� �� �Q �����/n � � or Boring Consiructed <br /> Numencal Street Address or Fue Number and City of Well or Boring Location �� / /r�� � <br /> 67`tV � � Rd RO � I�1 55391 Depth Before Sealing ��-= ft. Original Depth { - fl. <br /> �� Show exact location of well or bonng Sketch map of well or bo�ing Static Water Level ccurate <br /> in sec�ion grid wi�h��X`. location.showing property lines. <br /> N ., <br /> roads.and bwldings. ❑Approximate <br /> � � � � � <br /> 'i_ _i_ 'i_ _i_ � <br /> ,Single Aquifer ❑Multiaquifer , � ft. � below above land surface <br /> i i i i <br /> _i_ _�_ _i- -i- CASING TYPE <br /> W i i i i E <br /> � i i i <br /> -r -�- -r- -r <br /> i i i i � .\ teel ❑Plastic ❑Tile ❑Other <br /> -mile <br /> _i i i i_ � _�_ '... / / <br /> I I I � y <br /> 4. � �,� <br /> � Screen from� to �— fl- Open Hole irom to fL <br /> �—1 mile--� OBSTRUCTION/DEBRIS/FILL <br /> bstruction ❑Debris ❑Fill <br /> PROPE TY OW R'S NAME <br /> Leo�'Satx�y Eollock 471-7252 //� <br /> Type of debris/obsiruction ��tiF r� ����� � ���`- �,rf�i� <br /> Mailing Address d different than property address indicated above. <br /> - Obsiruction/Debris/Fill removed? Yes ❑No <br /> PUMP <br /> .Removed ❑Not Present ❑ Other �'L� ����� <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted7 <br /> � tl not known,mdicate estimated formation log from nearby well or bonng. � <br /> drift �in.from �to � ft ❑Yes �YJo ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑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 /> o Annular Space Exists <br /> ❑Annular space grouted with iremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> / <br /> � '�} <br /> Grouting material tiL/�%CEN�,/4�rom �to ��ft. yards �{bags <br /> from to ft yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to tt yards bags <br /> �� 9" w�elt I32' ��P (rom to ft. yards bags <br /> � ZZ �S �t UNSEALED WELLS AND BORINGS . <br /> 1'* 1FJri UCllt�� Other unsealed well or boring on property? ❑Yes <br /> ` 2 I�IEn �r� �g � C�� �'C�,�L � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION � <br /> � This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The informa6on contained in ihis report is <br /> true to the best of my knowledge. <br /> DOl1 $�Ol�O2.A �I.Z I}r�1�.�Tig e0.! �T1C. �7172 <br /> Contractor Business Name License or Registration No. <br /> I�. ���� �����5�` 9-3C�-93 <br /> h ed epresentative S�gnature Date <br /> H 429 0 5 J� �'`°�°n <br /> LOCAi-C;C�Y <br /> Name ol Person Sealing Well oi Boring <br /> H601434-01 <br />