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Minnesota Well and Boring <br /> wELL OR BORiNG LOCarION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD^^���eso�a u��q�e No. <br /> T���� Mmnesota Stafutes.Chap�er 103/ or W-senes No. <br /> ILeave blank iI not knownl <br /> Townsh�p Name Townsh�p No Range No. Section No Fraclion(sm �Ig) Dale Sealed Approwmate Date Well <br /> �� ��� 23 � ����'a � -� �/- or Boring Conslruc�ed <br /> �'S <br /> Numencal Slreet Address or F�re Number and City of Well or Bonng Lowt�on � / f <br /> 3�2 t� � � �� Depih Before Sealing ��� ft Ongmal Depth � ft <br /> SFww exact locat�on of well or bonng Skelch map of well or bonng Static Water Level Accurale <br /> in sechon gnd wdh��X��. IocaOon.showing property lines. <br /> , �-�� - � roads.and buddmgs. ❑Approximate � <br /> � � � 1 i _ , i ��+ f <br /> -- ---N-- -- , , i _ .._... �. <br /> � � � �� � $ ' Sin le A ui�er �'�' <br /> g q ❑MulUaqurfer fl. below above land suAace <br /> i i• <br /> i i ; <br /> _.. <br /> _i_ _a_ _i_ -- CASING TYPE <br /> W � � � 1 E <br /> - -�- <br /> i i �k � � _ ,�� Steel ❑Plashc ❑Tile ❑Other <br />� �- - �- --- -- - / / <br /> -� <br /> S I I � � Screen from /�� �o � f� Open Hole Irom to ft. <br /> �--1 mile—� �.' - OBSTRUCTION/DEBRIS/FILL <br /> Obs�ruction ❑Debris ❑Fill <br /> PROPERTV OWNER'S NAME <br /> d'eit Cam 428--2242 ,.,��i�...�� l�-''j�� � /�Ul7�/� <br /> Type of debris/obsirucUon <br />� Mailing Address d ddterent than propeAy address indicated above. € <br /> 1`i� v�j C nZ$� 1 O� � Obstrudion/Debns/Fill removed� es ❑No <br /> ROgCls, MN r55374 " PUMP <br /> Removed ❑Not Present ❑ Other �`"u" • "" �� <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO . <br /> FORMATION <br /> Diameter Depth Set in oversize hole9 Annular space initially grouted� <br /> If not known,ind�cate estimated lormation log irom nearby well or bonng. ,� / / <br /> � in.from S�lo � ft. ❑Yes �lo ❑Yes ❑No ❑Unknown <br /> in.from to n. ❑Ves ❑No ❑Yes ❑No ❑Unknown <br /> in.�rom to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> .o Annular Space Exists . <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casmg Perforation/Removal = <br /> m.irom to ft. ❑Perforated ❑Removed <br /> in.irom to fl. ❑Perforated ❑Removed <br /> Type of perforator �� <br /> ❑Other <br /> GROUTING MATERIAL <br /> / /�,>ly� /. / <br /> Grouting material /V�� ��`_'�/'�.�Y(6m G./ to �ft. yards �bags <br /> from to ft yards bags <br /> � REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to fl. yards bags <br /> from to fl. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes o <br /> � LICENSED OR REGISTERED CONTHACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The intormation contained in this report is <br /> � �rue to the best of my knowledge. <br /> � sc«�oi$ �i� cx��l� co� T�. 27272 <br />� Conhactor Busrness Na7ie ' �` �� /'��� License or Registrabon No. <br /> .�-�'', � / . �( � � <br /> Ji�'//.�✓ ��i��i����'_� <br /> GidlTo d Representative S�gna— ture� Date <br /> _.�- ��� _ <br /> {.� .. - . .,� . ,...__. � .. <br /> u�����' ■■ Name ol Person Sealmg Well or Bonng <br /> HE-01434-01 <br />