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-�-- - ---- , <br /> Minnesota Well and Bonng � � � <br /> WEIL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEA�TH Sealmg No. H <br /> �o��,YName WELL AND BORING SEALING RECORD M���eso�a u��q�e No <br /> j� Mmnesota Sta�utes.Chapter 103/ or W-series No <br /> {�y �� 1Leave blank il nol knownl <br /> 7 <br /> Township Name Township No Range No. Section No Fraction(sm. �Ig� Date Sealed Approximate Date Well <br /> )- or Boring Consiructed /c7' .,_� � <br /> � �14 �la �ra �~ /�- ` : 1 . .. <br /> i' <br /> Numencal Sireet Address or Fve Number and City of Well or Bonng�ocation J � � � <br /> � !�) - � DepthBeforeSeahng —.l �� � it. OngmalDepth �-•-� � it. <br /> � .��,� � �l 5 � > )✓:>✓i U <br /> Show ecact IocaOon ol well or bonng Ske ch map of well oi bonng Sla�ic Water Level QAccurete <br /> m section gnd w�th��X�� location.showing property lines. <br /> ��.. roads.and bwldings ❑Approzimate <br /> N <br /> -�- - �- --- -;- ;' ___ _ j 7 x <br /> ' ' - �t,��� �'� (�,Single Aquifer ❑Mulliaqwter fl. below aboe'e land surface <br /> i � i � f <br /> _�_ _ - -- `1L i CASING TYPE <br /> W 1 I E � .�.,-�—' ..-- <br /> i i i i i <br /> ' _�' _r_ _�_ <br /> ; � � � �� �� � j � � I�Steei ❑Piasuc ❑7de ❑Otner <br /> e , . <br /> � � �_ _ -__- _ �---_-= <br /> -- --- -, - -, <br /> � ' 1�,•.. <br /> Screen from to fl. Open Hole Irom to ft. <br /> S <br /> ���^�k� OBSTRUCTION/DEBRIS/FILL <br /> �-.Obs�rucl�on ❑Debns ❑Fill <br /> PROPEHTV OWNEH'S NAME <br /> � � � t J � f ` (� � <br /> �'7 <: f �_� TYPe of debns/obs�ruclion •/,t ' ���Y:�i' }�, �(—�. .� - ��-�. <br /> Mailing Address il drtferent Ihan propeAy address ind�caled above <br /> Obsiruction/Debris/Fill removed� ���es ❑No <br /> PUMP <br /> "r �-�. <br /> ❑Removed �Not Presenl ❑ Other <br /> CASING <br /> GEOLOGICAI MATERIAL COLOF HARDNESS OF FROM TO • <br /> FORMATION <br /> Diame�er Depth Se�in oversrze hole? Annular space irntially grouted� <br /> If not known,indicate esUmated lormation log irom nearby well or bonng. <br /> � � <br />� /� �_in.from i-' to } -�� � ft. ❑Yes �No ❑Yes ❑No /�Unknown <br /> �:' / <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> m.from to ft. ❑Yes ❑No ❑Ves ❑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 tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to fl. ❑Perforated ❑Removed <br /> m.irom to fl. ❑Pertorated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> � �� �' <br /> � <br /> Grouting material t�. �-^ " from � ' to J � ' ft. yards ��� � bags <br /> from �o ft. yards bags <br /> REMARKS,SOUHCE OF DATA,DIFFICULTIES IN SEALING <br /> irom to fl yards bags <br /> �.,j . �'i S. _ , <br /> �� from to it. yards bags <br /> � UNSEALED WELLS AND BORINGS �.�1���'� S! � � ! <br /> � / i1 , <br /> ! �� � .� i - Other unsealed well or boring on property? �Yes ❑No . �r '�-���. <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed m accordance with Minnesota Rules,Chapter 4725.The mformatron contamed in this report is <br /> � true to ihe best of my knowledge. <br /> ! ;. �` � j �jy <br /> Contractor Bus�ness Name License oi Registrafron No <br />�� f' t :.i.f � ;� .. <br /> i <br /> Aulhonzed Represe/rtafive Signature Da�e <br /> � � .. � , . � �� <br /> ������,��7�� � ���,�^�� Name ol Person Sealing Well or Borrng <br /> HE�Ot434-Ot <br />