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Minnesota Well and Boring 12 G�2 4 5 � <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> �o���Y Name WELL AND BORING SEALING RECORD M���eso�a un�q�e No. <br /> �E'11[l+'].�i F; Mmnesota S�atutes. Chapter 1031 or W-series No- <br /> ILeave blank il not known� <br /> Township Name Townsh�p No Range No Section No Fradion�sm. �ly) Date Sealed Approx�mate Date Well <br /> �^��F.�V��.e i.;t-[� 1 1�I\ ��i i4 �l+J i���j L����,7 L'1�� t};f t_` �j �r i� or Boring Construc�ed <br /> Numencal Street Address or Fue Number and Gty of Well o�8onng Location <br /> %�� 1'E.'��rlCtcilf' P.�1$� tYClY��1l DepihBeforeSealinq --.— ��.�—� it. OriginalDepth ft <br /> Show exac�locahon of well or bonng Sketch map of well or bonng S�ahc Water Level ��Accurale <br /> in seclion gnd with��X�. locahon.showing property hnes. <br /> roads.and buildings. ❑Approxima�e - <br /> N <br /> i i i i _._._.`' <br /> -- -;- -;- -- <br /> � ' � �Single Aqwfer ❑Multiaqwfer ft below above land surface <br /> i i i i <br /> -'- -�- -�- -�- � CASING TYPE <br /> W i i i i E � <br /> i i i i T ; . .. . 1. _ . <br /> __ _�_ _r_ _�- T � ; <br /> � i i � � �S�eel ❑Plashc ❑Tile ❑O�her <br /> � -mile i <br /> i i i �. ' � 1 �,. . .. . <br /> __ ___ __ ' <br /> i i i - �. �, �� <br /> S i � �, � Screen from to ft. Open Hole irom to ft. <br /> N--imile—�I � �' . OBSTRUCTION/DEBRIS/FILL <br /> ,R.QP Yyy� �Obstruction ❑Debris ❑Fill <br /> P!'; 1�t�TY�1 t RS.NAME � y r-. 1 . . <br /> "► . <br /> . �..-t. �. . . ,�"i _ ', � <br /> Type of debris/obstrudion <br /> Mading Address rf diNeren��han propehy alddress indicated above. <br /> Obstruction/Debris/Fill removed? 0 Yes ❑No <br /> �`:..�:}'I:�L�I�I��afi� : ri�SiL�� PUMP <br /> �.� �c�I'nd�lf. f;. ;:�-j !�(t,l� i: ' ._� ' _ ,. .� _ .! .. �{ . + 1 � t_ ��: . . . <br /> ��ctti".�%t�._k , �'��L � _���}1 �Removed ❑Not Presenl ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diarneter. . . Depih . Se�in overs�ze hole9 Annular space initialty grouted� <br /> If not known,indicate estimated formation log Irom nearby well or boring. , , „ �.► _, j :, <br /> in.from to it. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown -^ <br /> in.irom to fL ❑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 /> ❑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 /> ❑O�her � <br /> GROUTING MATERIAL <br /> �r' — 17 <br /> Grouting material from to fl. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. — yards bags <br /> I�` 1 �..�.�. � _ cF'� it'ti_�1' � i..��;3 �. -.� f - _ t <br /> .., ;.'..f.� .. ;�' t:' .'f '.. . . . from to fl. 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 m ihis report is <br /> true to the best of my knowledge. <br /> `�_� t �,:r���. -,;_'_;"l'i:R ;;EF�i' i ,_ �, �. <br /> Contractor 6usiness Name � // �//l�Cense or Registrat�on No. <br /> i � t:,a } — t,y 6.�- { .E`f` �; i/'� j . . _ <br /> . .. � ' � i -�_ � - { { ' { S�� ��'�..:��. �.�1 _1 i t'. ri ' . _ <br /> j ' i. I �,,,��-'�.-. <br /> i 1'.#��.�.s f r jl �� 1{ ! } � - ,_, , Authonzed Representative Signature { Da�e <br /> '�+ T��.�I4 �"�<.t��_Cii>.�' <br /> LOCAL COPY H 2 0 2 4 5 <br /> Name of Person Sealing Well or Boring <br /> HE-01434-01 <br />