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� Minnesota Well and Boring 2 8 8 5 9 WELL OR� ��+iiNG�oCaTioN �_.,. MINNESOTA DEPARTMENT OF HEALTH Sealing No. H �o�_��Y N�;,� WELL AND BORING SEALING RECORD M��esota un�q�e No. iit?T�1k='�%lf: Minnesota Statutes.Chapter i031 or W-series No. �Leave blank i�noi known) Township Narne Township No. Range No. Section PJo. Fraction(sm. �Ig.) Date Sealed Approximate Date Well i.;�,�Yf',. .�,�; �i ,�`, ._; or Boring Consiructed 14 l4 �4 �'�1 'f v Num1encal St�re7,e-t,�A,-ddress or Fre Number and City of Well ors.B�.o.,ring Location 1 i.{.;i a_�cv.E�1t��T� .�c�n� 1�(l�=i� a-�y. Depth Before Seahng ft. Original Depth -� ft Show exact location of well or bonng Sketch map of well or boring Stat�c Water Level ❑Accurate in section grid with��X��. location.showing property lines. � roads.and buildings. �Approximate N t.; � � � � i � �� Single Aquifer ❑Mul�iaquiter � � ft I . � below above land surlace -�- -�- -1- -�' � � ' \ � CASING TYPE W i i i i E ` � . � � � � � '� -r -�- -r- -i- . i � � � � � �,Steel ❑Plastic ❑Tile ❑Other o mile _I I I 1_ � . ... .+ ` .!'... t 1 I I I J � � .'� .�u., S Screen from to ' fl. Open Hole(rom to ft. �1 mile E � � f - OBSTRUCTION/DEBRIS/FILL ❑Obstrudion ❑Debris ❑Fill PROPERTY OWNER'S NAME €3x'i� F:r�rr Fi��7 Type of debris/obsiruction Mailing Address if different than property address indicated above. Obsiruction/Debris/Fill removed? ❑Yes ❑No �t1E` :r. �:SI�+ zrt';4tia.3�y PUMP i�'y2.'�+-..��, :'fi. _.. �y'� �Removed ❑Not Present ❑ Other CASING GEOLOGICAL MA7ERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depih Set in oversize hole7 Annular space initially grouted? If no�known,indicale estimated forma�ion log from nearby well or boring. _ � ) i ,,' `� in.from to �"�l ft. ❑Yes �,No ❑Yes ❑No ❑Unknown �� `. =� in.from to ft. ❑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 wi�h tremie pipe ❑Casing Perforation/Removal in.from to fl. ❑Perfora�ed ❑Removed in.irom to fL ❑Perforated ❑Removed Type of perforator ❑Other GROUTING MATERIAL i Grouting material �� i-�� from to � ; ft. yards � bags from to ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING from to f� yards bags from to k yards bags UNSEALED WELLS AND BORINGS Other unsealed well or boring on property9 ❑Yes �No LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in ihis report is irue to the best of my knowledge. i�l7n ��r;LL'.In€� ►e�:L,+_: Iih�:ut�Tl�iC.; C;t:., :li�(�. �:t3i:_ Contractor Business Name License or Registration No. _.—"'.-. ; � i �—�-93 �-�„ ufhonzed Representa�ive Signature Date �-.rLf_.C'j.� ��:A��PY H 2 8 8 5 9 ��,��, _ . _.�. Name of Person Sealrng Well or onng HE-01434�01