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Minnesota Well and Boring ��111 -- � WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H � � � �o��YName �.. WELLANDBORINGSEALINGRECORDMi��eso�a��iqUeNo. .;� 1.1,I iri�'�_:=i: or W-series No. rs�'�.� Minnesota Statutes.Chapter 103! � �Le2ve blank if not known� Township Name Township No. Range No. Section No. Frac�ion(sm. �Ig.� Da�e Sealed Approximate Da�e Well � ' � � or Boring Construc�ed �_,_L.�L: �� 2�4 � s� s�n sB,� ` ' �� `i 3 Numerical Street Address or Fire Number and City of Well or Boring Location —/t ��'t �'��+�-��-'��x Depih Before Sealing � � • fL Onginal Depth � � � ft. Show exact locahon of well or boring Sketch map of well or bonng Static Water Leve� ccurate in sec�ion gnd wdh��X��. Iocaiion.showing property lines. ' � roads.and buildings. ❑Approximate N � � � � � __ ___ _-_ __ Single Aquder ❑Multiaqui(er ft. � below above land surface i i i i �� >1�\ �,i1!.;��'"-. _i_ _�_ _i_ _i_ � �"`�'� CASING TYPE W i i i i E �.. . . �� � i � � _i_ _�_ _r_ _i_ ,, i i i i � � � Steel ❑Plas6c ❑Tile ❑Other hmile i K•� _i_ _i_ _i_ _i '_ / .__..-� �] S � Screen from � ` to t � ft Open Hole from to 1t. �--imi�e--►I , � OBSTRUCTION/DEBRIS/FILL Obstruction ❑Debris ❑Fill s� PROPERTY OWNER'S NAME Bietmsn tJ c� b b;t r i,,�� ;c��,-� Type of debris/obsiruction Mailing Address�f ddferent than property address indicated above. Obstruction/Debris/Fill removed7 Yes ❑No PUMP ❑Removed Not Present ❑ Other CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depih Set in oversize hole? Annular space initially grouted? If not known,mdicate estimated formation log from nearby well or boring. �ift � !7'1 � in.from v to � � fl ❑Ves L.�No ❑Yes ❑No ❑Unknown i� in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exisis _- ❑Annular space grouted with tremie pipe -� � ❑Casing PeAoration/Removal � �'�� in.hom �o fl. ❑PeAorated ❑Removed � in.from to fl. ❑Perforated ❑Removed �A�,� ,� .2 J Type of perforaror ❑o�he� GROUTING MATERIAL � Grouting material N�C�� L'y.dv�.��rom �` to i 1 7 it. yards ��bags from to fl. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING (rom to ft. yards bags V��,t� �t~ �l„1 1,77� LLCcP from to ft. yards bags 1V �� t UNSEALED WELLS AND BORINGS � 1� 1� d/Ciit�� Other unsealed well or boring on property? ❑Yes No 2 P.�n 3.�SW=� r��j� C� C�I� ��'Q(,at '� LICENSED OR REGISTERED CONTRACTOR CERTIFICATI N � This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information conlained in this report is true to the best of my knowledge. ��;�� ic��r.��x �,�°�1t., �:�:�.a;�:.� �:;., :�.x�.:. '��;�� Contractor Business Name License oi Registration No. �-- � �' 4-19-93 a ,�.�-�_..� �..�..��-�'..;: Authorized epresentative Signature Date LOCAL COPY �„I A Q .�� Tj.ID I�[� LQ p Name ol Person Sealing Well or Boring H E-01434-01 -.-_.—.�__