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Minnesota Well and Boring H 4 0 215 <br /> WELL OR BORING LOCanON MINNESOTA DEPARTMENT OF HEALTH Sealing No <br /> County Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No. <br /> � Minnesota Statutes.Chapter 1031 or W-series No. <br /> ILeave blank if not knownl <br /> Township Name Township No. Range No. Section No. Fraction(sm. •Ig.) Date Sealed Approximate Date Well <br /> /�.�,�,�� q' r� , or Boring Cons�ructed <br /> l.11UaAJ 11� 4J � ` � � . '` . <br /> ��a t_-v��.,,� � � c� <br /> Numerical Sireet Address or Fire Number and City of Well or Boring Location <br /> 1•1LQ 7..1_,,,..,t� �� /\,,,r.� 1�R.7 Depih Before Seahng �� ft. Original Depth `� r ft. <br /> a.O�3� �J6lC1�YJ. u3.UllV rll7 <br /> Show exact location of well or boring Sketch map of well or bonng Sta�ic Water Level Accura�e <br /> in sec�ion grid wdh��X��. bcation.showing property lines. <br /> N � , roads.��ryd buildings. ❑Approximate <br /> � � � � <br /> � � � ••,3 /!'J 'S�_ <br /> -,- -,- -r- -; <br /> `ti Single Aquifer ❑Multiaqui(er —�.e.;a�fl. � below above land surface <br /> � � � � �y. <br /> _i_ _�_ _i_ _i- CASING TYPE <br /> W i i i i E � <br /> � i i i � � <br /> -r -�- -r- -r <br /> � � � � Steel ❑Plastic ❑Tile ❑Other <br /> 'i.mile <br /> _� � I I_ � � <br /> I I I 1 ''� � <br /> Screen from� to ��-'-1 ft Open Hole from to ft. <br /> S <br /> �—1 mile—►I OBSTRUCTION/DEBRIS/FILI <br /> PROPERTY OWNER'S NAME � Obstruction ❑Debris ❑Fill <br /> Bn�ce Fei.k 473--3T59 — <br /> r _� ;, <br /> Type of debris/obstruction � � ���� C'� <br /> Mailing Address if different than property address indicated above. � <br /> Obstruction/Debris/Fill removed? �Yes Y 0 No <br /> PUMP <br /> ❑Removed Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATEHIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> t � � <br /> �rt O p.� in.from to �� ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> .a �.� <br /> in.irom 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 /> y�rvo Annular Space Exists <br /> ❑Annular space grouted with tremie 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 /> Grouting material��'�',:�� '" � � '�t from `� ' to ��� � ft. yards �bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> �t� �� ��� ��! �� from to ft. yards bags <br /> � ���^ C�,�,,.�j UNSEALED WELLS AND BORINGS <br /> 6 IG73 ��W Lit� Other unseated well or boring on property? ❑Yes No <br /> 2 1T� 1$Wr� rig & C�C ,��C �� LICENSED OR REGISTERED CONTRACTOR CERTIFICAT�ON <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> _ true to the best of my knowledge. <br /> Do� Stodal.a Wei2 Drill.ing Co., Itdc. 27172 <br /> Contractor Business Name License or Registration No. <br /> a <br /> "�';' ",/'���- 8-27-93 <br /> on epresentaGve§ignaNre ° Date <br /> LL%i.H�COP'Y I„I � T�lil I�[!�C£ <br /> Name ol Person Sealing Well oi Boring <br /> HE-01434-01 <br />