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Minnesota Well and Boring 2 8 8 01 <br /> wELL oR BORING�oCA7ioN MINNESOTA DEPARTMENT OF HEALTH Sealing No. H -,� <br /> �o���Y Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No � <br /> i � � Minnesota Statutes.Chapter 103t or W-series No. <br /> ILeave blank il not known) <br />�i. <br /> Township Name Township No. Range No. Section No. Fraction(sm. •Ig.) Date Sealed Approximate Date Well <br /> �;��� ' ,,. y ' � �`] S or Boring Construded � <br /> s-:; �n�la�in �� [ �-� 1 <br /> s�' Numencal Sireet Address or Fire Number and City of Well or Boring Locahon � <br /> (� �: <br />�� Depth Before Sealing " � ft. Original Depth �� Fl. „�� <br />��-� Show exact locahon of well or boring Sketch map ot well or bonng Stalic Water Level Accurate � <br />� '� -fn sec�ion grid with��X��. loca�ion,showing propehy lines. <br /> N roads.and buildings. ❑Approximate <br /> -i- -i- -i- -� !� � � . � � <br /> Single Aquifer ❑Multiaquiter '" � fl below above land surface <br /> i i i i <br /> s-�- _i_ _�_ _i_ _i_ � CASWG TYPE �` <br /> ` W i i i i E �' � <br /> t � � <br /> � � � � T ;,. �' , <br /> �_. _i_ _�_ _r_ _i- �` ,y"� `� <br /> � � i � ,m_�e Steel ❑Plas�ic ❑Tile ❑O�her .k <br /> _i i i i_ � -� � <br /> o- ' i_ _ 1_ _i _ _i � <br /> S Screen from �'O G to � tL Open Hole from to ft <br />� � <br /> y - 1 mile <br /> � � OBSTRUCTION/DEBRIS/FILL <br />��� PROPERTY OWNER'S NAME Obs�ruction ❑Debris ❑Fill � <br />�� �{ ` � <br />� Atli]I�ttE�' W@LffiOL� �J �'...£,,, �.S v'�ti^ �✓�i s'��C� L c7� �,c��nc. � <br /> Type of debris/obstruction ,� <br /> Mailing Address if different than property address indicated above. - <br /> Obstruction/Debris/Fill removed? Yes ❑No ? <br /> ',�� : ..�_., � . : PUMP ,�"� <br /> L; - � . , .. . � <br /> r� <br /> Removed ❑Not Present ❑ Other ,(� <br /> �' CASING � <br /> HARDNESS OF �? <br /> GEOLOGICAL MATERIAL COLOR FORMATION FROM TO <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 />� �.�f� � � �in.from -LL to � ft. ❑Yes p�No ❑Yes ❑No ❑Unknown ?' <br />�,� � <br /> t��' in.irom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br />°=�:;' <br />� In.from to ft ❑Yes ❑No ❑Yes ❑No ❑Unknown <br />�; <br /> ��,i:' METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br />'„�-:� �No Annular Space Exists <br /> . ❑:�nnular space grouted with tremie pipe <br /> <'. <br /> ❑Casing Perforation/Removal <br /> � c <br /> � •� in.from to ft ❑Pertorated ❑Removed <br />'nFi> in.from to fL ❑Perforated ❑Removed <br />�:;i�: � . . �` . <br /> i r <br />.� � Type of perforator � <br /> � <br /> �� � <br /> ^ _ _ - ❑Other � <br />�-r; : <br />�,;. GROUTING MATERIAL <br /> {� `/ Pr '� r. <br />>�o Grou6ng material 4"`�-�R�{ `"'£'M � from � to �ft. yards �,�bags <br /> g�� from to ry, yards bags '4-_.a� <br />'�:: <br /> "- REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br />� <br />'�-`- irom to ft. yards bags <br /> Fi'` <br />��`' �L'd11� Z~ 1�1'�'u E31i� � <br />� 2 1,..8 C��♦ . � from to fl. yards bags <br /> _. ! It�.. 1.,,_,.t,.�.d�e UNSEALED WELLS AND BORINGS <br /> +t Uia �JGLl VELR <br />�`;' A_.,_ t..L��! _.{n t. �� �iw � Other unsealed well or boring on property? ❑Yes No F, <br /> L�tXld 1#3W i$ �s �vaiL �_ <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATIdN <br />��;_:` This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> . . true to ihe best of my knowledge. <br /> � � aa: �.. � . - <br /> ``.�' D0�1 SCOC�:0�.8 W��.1 D��.Z� CA.� �17C. 2717� <br /> � �,� '"`=' - Contractor Business�e License or Registration No. <br />�� � . - �� �. ./� /' � 5"17"g3 <br /> � � <br /> ��' r�' , <br />�;��:;, Aut nzed RepresentatNe Signature Date <br /> l r � �R� i�C1SHL� <br /> LOCAL COPY '„I �n(�O� ` <br /> 8 8 Name ol Person Sealing Well or Boring <br />�`���,�"HE-01434-01 � <br /> _ ,� <br />