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Minnesota Well and Boring 4 4 8 6 � <br /> �'� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealmg No. H <br /> �o���Y Name WELL AND BORING SEALING RECORD M���esota un�Q�e No. <br /> p� _ �� Minnesota Statutes.Chapter 1031 or W-series No. <br /> �qp�1p��„ fLeave blank il not knownl <br /> .. JYf <br /> Township Name Township No. Range No. Section No. Fraction(sm. •Ig.) Date Sealed Approximate Date Well <br /> � ��� � �� �n��t '/4 � n or Boring Cons�ructed <br /> D�lh/ 1 � �'i <br /> _ Numencal Sireet Address or Fire Number and City of Well or Boring Location �ry � � <br /> 35� ": .g�{)j'� �,j�Q ir[i�� 55391 Depih Before Sealing �G�r,� fl Original Depth 1 �� ft <br /> Show ezact location of well or boring Sketch map of well or bori g Static Wa�er Level ccurate <br /> in sedion grid with��X��. 7 s location.Sabwing property lin s. <br /> � � �v roads.and buildin s. ❑Approxima�e <br /> N . <br /> � � � i <br /> � I <br /> _i_ ___ 'i_ __ <br /> ingle Aquifer ❑Multiaquifer � ft. � below above land surtace <br /> i i i i <br /> _i_ -�- -i_ -i- CASING TYPE <br /> W i i i i E <br /> � � � � <br /> -i- -�- -r- -r - <br /> i i i i — teel ❑Plastic ❑Tile ❑Other <br /> mile <br /> I 1 I I ' / <br /> I I I I } �(�, � ��) <br /> S � Screen from�--�— to �— fl. Open Hole from to ft. <br /> �--i mi�e—� ,.,,.. /. . . � ,� ���� l<l. OBSTRUCTION/DEBRIS/FILL <br /> � �ObsVuction ❑Debris ❑Fill <br /> PROPERTY OWNER'S NAME <br /> 7.�1� �Sc:Kirs�e �rli b73 i�c,P �/�f g �UIY►(3 <br /> - Type ot debris/obstruction <br /> Mailing Address d different than propeny address indicated above. <br /> Obstruction/Debris/Fill removed? �es ❑No <br /> PUMP <br /> Removed ❑Not Present ❑ Other �t;��- �luf�,(� <br /> CASING <br /> GEOLOGICAL MATERIAI 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 irom nearby well or boring. � � <br /> a��t O �� �in.from �to _!— ft. ❑Yes �iJo ❑Yes ❑No ❑Unknown . <br /> 11L 1 <br /> in.from to ft. ❑Yes ❑No ❑Ves ❑No ❑Unknown <br /> in.from to fL ❑Ves ❑No ❑Yes ❑No ❑Unknown <br /> . METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> o Annular Space Exists <br /> ❑Annular space grouted with iremie pipe <br /> ❑Casing PerforatioNRemoval <br /> - in.from �o fL . ❑Perforated ❑Removed <br /> in.from to fL ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> ,�! �+ r /� <br /> Grouting material ti�-�� C—�r���rom �_to /Z/) ft. yards �t„�bags <br /> from to fl. yards bags . <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> c�c�a 4„ �u �.zo• a�� <br /> lo �w� ��� from to ft yards bags <br /> �x� <br /> le��, �t�t� UNSEALED WELLS AND BORINGS <br /> L��i <br /> � �wy�r' r�o � ��* ��� � Other unsealed weli or boring on property? ❑Yes No <br /> KfIN fj e.. <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <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 /> F�ii StbC�.0�8 � �l�fllg �i0.� �$C. Zn� <br /> Contractor Business Name License or Registration No. <br /> y;,a��,�'�„_� - ` - ��—�� <br /> Author¢ed Representafive Signalure �e <br /> �OCAL COPY H 4 4 8 6 fi `'�"' �'`°� <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-01 <br />