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Minnesota Well and Boring <br /> WELL OR BORING IOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Mi��esoca u��q�e rvo. <br /> ����� Minnesofa Statutes.Chapter 1031 or W-senes No. <br /> ILeave�lanx il nol known� <br /> Township Name Township No Ranqe No SecUon No Fraction(sm �Ig.) Date Sealed Approximate Date Well <br /> or Boring Conslructed <br /> �«� I17 zs o� a�—cx�2e.a F <br /> Numencal S�reet Address or Fue Number and City ol Well or Bonng Locatwn �y���---yyy / / ��; / <br /> 99/.�1 .t,7 Ci.�re T... �O� Depth Bebre Sealing ��r.I C�� ft. Onginal Depih J ...�— fl. <br /> .JJ�fG 'Y 7IN /✓1 <br /> Show exacl�cealion of well or bonng Sketch map of well or bonng Static Water Level Accurate <br /> m sec�wn gnd with��X��. locatwn.showing propeAy hnes. � <br /> . . �"���""�'"' roads.and bwldmgs ❑Approwmate <br /> N ( � <br /> � � �- � � � ' i <br /> -- -- -r- -,s <br /> � � , _.._._.., <br /> Single AQuder ❑MulGaqwfer �ft. � below above land surtace <br /> ; <br /> -�- -�- -`- -'- :..---�--_� ,----_.._.__�. ._ CASINGTVPE <br /> W ' ' E } � <br /> � � � � � <br /> - -,- -�- -�- <br /> i � i �� � ,_,____�_�_______ �Steel ❑Plashc ❑Tile ❑Other <br /> _i_ _�_ ___ __ �y r , . , . , / � r <br /> � ( ��/ <br /> i Screen from�-a.1--�— Io �� fl. Open Hole from lo ft <br /> �'—�S'k� .%� , , .t"-f j'�'� OBSTRUCTION/DEBRIS/FILL <br /> ObsVuction ❑Debns ❑Fill <br /> PROPERTY OWNER'S NAME <br /> ype ol debris/obstructwn..,� �JA�`� ���� � ���� <br /> Mai6ng Address d ddf rent t an propeAy address indicated above. <br /> Obsiruction/Debns/Fill removed? es ❑No <br /> 140Q0 Veit Place PUMP <br /> Rogers, P�+I 55374 2 of Z ,5,�� r�U�lo <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 not known.indica�e estimated formation log from nearby well or bonng. � / <br /> / /� � <br /> �"�.in.from �,,.L to fl. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> f <br /> '� ���1 in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> l <br /> in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAH SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> o Annular Space Exists <br /> Annular space grouted with�remie pipe <br /> ❑Casmg Perforation/Removal <br /> in.from to fl. ❑Perforated ❑Removed <br /> in.from to n. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑O�her <br /> GROUTING MATERIAL <br /> Grouting matenal�ll/�Ap C.��� �to �ft/ yards / f bags <br /> from to ft. yards bags <br /> REMAHKS,SOURCE OF DATA,DIFFICULTIES IN SEALING � <br /> F <br /> hom to fl. yards bags <br /> irom to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property7 ❑Ves �No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minneso�a Rules,Chapter 4725.The informadon coMained in ihis repon is <br /> true to ihe best of my knowledge. <br /> Don Sta.io2at�ell Dr3.l.lir� Co., Inc. 271?2 <br /> Conhactor Busrness� �; License or Registia6on No. <br /> � <br /> /���� ��- �_��' f• �l �: <br /> on d RAp`ieserN3�ve SignafLre � Dafe <br /> .__.__..r ----"`..�.. <br /> --`�- . _ •' . .� . ., .._._.. „ \,�- <br /> H _.._ _ �-.,_ <br /> �. <br /> �„�,���' � Name o!Person Seahng Well or Bonng <br /> . HE-Ota3a-01 <br />�. _ <br />