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Minnesota Well and Boring <br /> wELI OR BORiNG LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> �o��� e WELL AND BORING SEALING RECORD M���eso�a u��Q�e No. <br /> � Minnesofa Stafutes.Chapter 703/ or W-series No. <br /> ILeave blank A nol known� <br /> To hip Name ownship No Range No. Section No Fraction(sm. �Ig� Da�e Sealed - Approzimate Date Well <br /> � } t-� or Bonng Constructed <br /> t IQ t <br /> umencal Streel Addre s or ire mber and City ol ell r Bonng oca n ' <br /> / � <br /> �� Ar./ Deplh Before Seahng ,�--/ it. Onginal Depih ft. <br /> Show exa bcahon o well or bonng Sketc map of well or bonng Static Water Level 0 Accurate <br /> �n section gnd wAh��X . locatron.showmg property hnes. '� <br /> roads.and bwldings. ❑�Approximate <br /> N <br /> � � i <br /> -,- c ., <br /> � Smgle Aquifer ❑MulUaqwfer � ' fl. ��`-� below above land suAace <br /> i i <br /> _�_ _i_ -i_ CASING TYPE <br /> W E <br /> � � � � <br /> i , i i � �Steel ❑Plastic ❑Tile ❑Other <br /> mi�e <br /> '�' _ �_ _� _ __ •� <br /> � . 1 <br /> S ' Screen irom �.`, to -- fl. Open Hole from to ft. <br /> �""'k� OBSTRUCTION/DEBRIS/FILL <br /> ❑Obs�ruction ❑Debns ❑Fill <br /> PROPE�T_Y_OWNER'S NAME <br /> �.. r ' <br /> � Type of debns/obsiruchon <br /> Maihng Address d ddferent than propeny address mdicated above. <br /> Obstruclion/Debns/Fill removed? ❑Yes ❑No <br /> PUMP <br /> �Removed ❑Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS Of FROM TO <br /> FORMATION <br /> Diameter Dep�h Set in oversrze hole? Annular space inAially grouted? <br /> If nol known.indicate estima�ed brmation log irom nearby well or boring. <br /> �� m.irom �_to ��_� fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to fl. ❑Yes ❑No ❑Ves ❑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 /> [�.No Annular Space Exisis <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perfora6on/Removal <br /> in.from �o ft. ❑Per�orated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> Grouting material w T! from ��Y 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 /> from to fl. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or bonng on property? ❑Yes ❑;No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> JA N 1 0 1996 This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725 The information contained m ihis report is <br /> �rue to the t of my kno�dge. <br /> ` /, /`�' �,, <br /> , fracYel ne _ � License or Repisf �ion o. <br /> 7 <br /> •'l�J� 1�� ��� .G ' J�. -- .. <br /> / <br /> Autlionzed n a r gnaWr- ' Date .• <br /> ✓/ � � /'� <br /> � -;;! ,i' �_. <br /> �L��„Sr.;p��'�f' � � Name o!Person!Ea ell� goring � <br /> HE-01a34-Ot <br />