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Minnesota Well and Boring ��O ^ � <br /> �� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H �� <br /> �o���Y Name ` WELL AND BORING SEALWG RECORD M���esota u��q�e No. <br /> � Minnesota Statutes.Chapter 103/ or W-series No. <br /> fLeave biank�f nol known7 <br /> Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approzimate Date Well <br /> j ,.. or Bonng Constructed . <br /> �ia �la �ra t ` � _ . � � . <br /> Numencal Street Address or Fire Number and City of Well or Boring Location <br /> � "'>; <br /> -. � : ,�. ��}� ��„ "�. r � l n V Depth Before Sealing ��� f�. Original Depih ft. <br /> c . .i.3 ,.n� <br /> Show exact location of well or bonng Ske�ch map of well or boring Static Water Level �Accurate <br /> m section grid wdh��X��. location.showing property lines. <br /> roads.and buildings. ❑Approximate <br /> N <br /> _-1 <br /> -�- -;- -;- -;- ,���� L_ ; .. <br /> �..Single Aquifer ❑MWtiaqwfer ft. below above land suAace <br /> i i i i -.._� <br /> _i_ _�_ _i_ _i_ `-�- CASING TVPE <br /> W i i i i E / , <br /> � � (�.�, � <br /> i � � � (t i <br /> -r -�- -r- -r j <br /> � � � � mile . (j,�,! � �-Steel ❑Plastic ❑Tile ❑Other <br /> .� i _ i i _ '�� ' �+��. � %� <br /> -i i -i- i ��: i-r- � _... <br /> S � � �,..... Screen from to ft Open Hole from to ft. <br /> �-i mile-� OBSTRUCTION/DEBRIS/FILL <br /> �ObsVuction ❑Debris ❑Fill <br /> PROPERTY OWNER'S NAME <br /> ) Type of debris/obs�ruction 1� �1 <br /> Maiting Address d different than property address indicated above. � <br /> Obstruction/Debris/Fill removed? �Yes ❑No <br /> PUMP <br /> �Removed ❑Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FHOM TO <br /> FORMATION <br /> Diameter Depth Se�in oversize hole? Annular space irntially grouted? <br /> If not known,indicate estimated formation log hom nearby well or boring. <br /> \ <br /> `J�J / iQ in.from to ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> ! q. <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑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 Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to fl. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perfora�ed ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATEHIAL <br /> Grouting material P�. � � from 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 /> S-- <br /> � irom to ft yards bags <br /> UNSEALED WELLS AND BORINGS <br /> � , � O�her unsealed well or boring on property7 ❑Yes �,No <br /> � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> i 'tt � <br /> Contractor Business Name License or Registration No. <br /> � .. <br /> Authorized ReprBsentative Signature� Date <br /> 58049 ` ' � <br /> LOCALCOPY H ' <br /> Name ol Person SeaOng Well or Bonng <br /> HE-01434-01 <br />