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Minnesota Well and Boring n WELL OR BORWG LOCATION MINNESOTA DEPAFiTMENT OF HEALTH Sealing No. H ��O lJ H _.. WELL AND BORING SEALING RECORD M��nesota u��q�e 2 � g� County Name or W-Series No. �� Minnesota Statutes.Chaptei 703/ ��edVe b�a�k o �� .,,,,��'. Township Name Township No. Range No. Sedion No. Fraction(sm. �Ig.) Date Sealed A r imate Date Well .� or Boring ConstrudeYf .�v�.�� �rran�� t 17 7 3 17 a 1;;{?ti�,� �„ ^ -. ,,, �L;:IIl F: ~-� ,: Numerical Street Address or Fire Number and City of Well or Boring Locahon .y� � ` 3329 C�y::'�c�1 A[3y swa,�,i ��(14� �� Depth Before Sealing G t (t Original Depih '�-�-; ft. Show exact bcahon of well or boring Sketch map of well or o�ng Static Water Level �Accurate in section grid with��X��. location.showing propert Gr� roads,and bui � s. ❑Approximate N _i i i i_ —'----�--r / i_ _i_ _i_ _i �Single Aquifer ❑Multiaquifer ��ft. � below above land surface i i i i � \ _i_ _�_ _i_ _i_ ,ti, �'`� CASING TYPE W i i i i E � �� i � � � _i_ _�_ _r_ _�_ � � � � �/ , teel ❑Plastic ❑Tile ❑Other e mile * i i i i 0� -.__._.. _i_ _ _ _1 _ _I � � r l I S Screen irom �� to 4 � fl. Open Hole from to ft. N— 1 mile� �.._� . OBSTRUCTION/DEBRIS/FILL ❑Obsiruclion ❑Debris ❑Fill PROPERTV OWNER'S NAME J�.ue HC1�Z Type of debris/obsiruction ��f Mailing Address rf different than property address indicated above. Obstruclion/Debris/Fill removed? ❑Yes ❑No [�t/R .3� PUMP Nr�.-�rre, I�. ��;�a� � � �1 ❑Removed Q�pt Present ❑ Other � CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depth Set in oversize hole? Annular space initially grouted? I(not known.indicate estimated forma6on log irom nearby well or boring. � i' � �L in.irom �—�o —� ft. ❑Yes �No ❑Yes ❑No ❑Unknown in.from �o fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to tt ❑Yes ❑No ❑Yes ❑No ❑Unknown METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: i �No Annular Space Exists - ❑Annular space grouted with tremie pipe ❑Casing Perforation/Removal in,from to fL ❑Perforated ❑Removed in,from to fL ❑PeRorated ❑Removed ; Type of perfora�or ❑Other GROUTING MATERIAL I Groutingmaterial^AJ.��f �.L/�r�,<./from � ro �-� ft. yards �_bags from to ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING from to ft. yards bags from to ft. yards bags UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑Yes o LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this repoA is true to thGY�q f y n le e. C�rt� {�()'{�� y,1p� �y- 7��,yv 1.JlAY ��'i ♦*.-•.�.� i�.i 1�l�I t`rl� U_'.� tav�.. L 7� �[`. Contractor Business Name License or Registration No. " _.,......, ,• ! "� ��. ,�"/-i'� � �- ...- 6-2f�i `Q'uthorzi ed Representatrve Signature Date LOCAL COPY H 5 5 0 0 8 J�.1ll AlltOIiS�] Name of Person Sealing Well or Boring HE-01434-01