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Minnesota Well and Boring <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD^^��^eso�a u��q�e No. <br /> Mmnesota Statutes.Chapter 103/ or W-series No <br /> � ILeave blank i1 not knownl <br /> Township Name Township No Range No Section No Fraclion�sm. �Ig� Date Sealed Approximate Date Well <br /> `� �� or Bonng Consiructed <br /> Orano lI? 2 ',° .� <br /> Numencal Slreet Address or Rre Number and CAy of Well or Bor�nq Localion �.�,+ i � <br /> 3350 2d �hore l�i Depth Before Sealmg �� �� ft Onginal Depih ��� ft <br /> Show exact locatan of well or bonnq Sketch map of well or bonng Static Water Level Accurale <br /> in 5ection gnd wAh��X��. loca�ion.showing propeny hnes. , � <br /> roads.and bwldings ❑Approwmale �J���� <br /> N � (� <br /> i R (�� <br /> -- -�- --- -- `4., �Smgle Aquder q <br /> .______,� ❑Multia wfer �fl. " below above land suAace <br /> _�_ _�_ _i_ _i_ � �� _. CASING TVPE <br /> W i i i i T + <br /> -i- -�- -f- ET F <br /> � i i '� ' �"'��"' � �Steel ❑PlasOc ❑Tile ❑Other <br /> _�_ ___ _L_ /� � / <br /> � Screen from=���— to / "' ft. Open Hole Irom to ft. <br /> �— �S���� �J - ,_ � ';� 08STRUCTIONlDEBRIS/FILL <br /> Id,ObsirucUon ❑Debris ❑Fill <br /> PROPEHTV OWNER'S NAME / ) <br /> '�eit Co Type ol debns/obstruction �N�"�� ��f'�� ¢ ����i" <br /> Madmg Address d ddterenl Ihan prope�y address indicated above. <br /> ObsirucUon/Debns/Ftll removed7 ❑Ves ❑No <br /> I4000 Veit Pl�ce PUMP <br /> Roge=s, �`41 5 5 374 <br /> emoved ❑Not Present ❑ Other ��� ���� <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO • <br /> FORMATION <br /> Diameter Depth Set m oversrze hole7 Annular space irntially grouled� <br /> If nol known,indicale es�ima�ed brmalwn log from nearby well or boring. �/ ^i .�,/` <br /> '„t ' ; � �� L/ In.from O to �S1 ft. ❑Yes I�IJo ❑Yes ❑No ❑Unknown <br /> � ri <br /> ! 3 in.from to ft. ❑Ves ❑No ❑Yes ❑No ❑Unknown <br /> tJ <br /> in.from to ft. ❑Yes ❑No ❑Ves ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> m.from to ft. ❑Perfora�ed ❑Removed <br /> in.irom to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑O�her <br /> GROUTING MATERIAL <br /> ""r- / <br /> �J<�+i�C'G!!'1��(�' U /�, � <br /> Grouting material, r m to 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 ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Ves o <br /> LICENSED OR HEGISTERED CONTRACTOR CERTIFICATION <br /> This well or bonnq was sealed in accordance with Minnesota Rules,Chapter 4725.The informahon contained in Ihis repoA is <br /> � Irue to ihe best of my knowledge. <br /> T)c� Stodol� W�II brillir� �o., Inc. 27272 <br /> Confractor Business Name Lrcense or Reg�strafion No. <br /> � /i i... <br /> i �_�-- � '� ' . , <br /> ,, :, �—_,�. - ,��. ., _ <br /> . ' . , .� .. s . ' <br /> �:/�` -T'G�-...- � <br /> Auf nze RepresentaGve Signature Dafe <br /> ___�� f <br /> ' .. � ..—-. . �' . .,s_:�.p:'+ - ._, ". <br /> H .�_r . _..,_ .� <br /> � *��� Name ol Person Sealrng Well or Bonng <br /> -� HE-07434-01 <br />