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wE�i U�BORING LOCA7iON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 1_ 2 6 5�5 <br /> Counry Name <br /> , WELL AND BORING SEALING RECORD Mennle9oNaUniqueNo. <br /> I���t1ii��)1I: Minnesota Statutes,Chapter f031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section Na Fraction(sm.-►Ig.) Date Sealed Date Well or Boring Constructed <br /> Grc:n� i i i �3 ['7 ''') <br /> % '/a '/a �:e �(. �J l' / <br /> Numerical Street Address or Fire Number and City of Well or Boring Location V� � <br /> (�5 <br /> �����S �ry�^�p1��Idre ��1�7� C'Jr -L.,���1� � Depih Before Sealing �1� ft. Original Depih r•� R. <br /> Show exact location of well or boring Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". 5���j 4 location, showing property Singie Aquifer ❑ Multiaquiter � <br /> lines,roads,and buildings. <br /> N WELUBORING Measured ❑ Estimated <br /> � � � �--�� ���'�-��- Water Supply Well ❑Monit.Well i <br /> � <br /> � � � � <br /> -T- -T- -�-- --�-- �l� �/ <br /> I I I I _ . _ � � _._.. . ❑ Env.Bore Hole ❑Other ft. ,e9�pelow ❑above land surface <br /> W --�- -�` -�-- --i-- E . CASING TVPE(S) <br /> \ <br /> ' ' ' E <br /> � � <br /> K <br /> . � <br /> � � � � <br /> —�' -i-- -i-- --�-- � 4I" . � Steel ❑ Plastic ❑Tile ❑Other ,�_ <br /> Y.mile _.__._..._�i�.__ . <br /> � � i i "`. <br /> -�-- -�-- -�-- --�-- � - /"_,� -'.,.. CASING �.. <br /> Diameter Depth � Set in oversize hole? Annualar space initially grouted? <br /> � S /:� i "� �/ C� ��� Yes �No ❑ Yes No Unknown <br /> t mi�e� .. -.. .- -- _.. . in.from to - ft. ❑ ❑ ❑ <br /> PROPERTV OWNER'S NAME p�ug ���ei�� in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Property owner's mailing address if diHerent than well locatiopn address indicated above. in.from to R. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> li�G—���'fC� <br /> SCREEWOPEN HOLE , <br /> ? <br /> Screen from �''�- to � � ft. Open Hole from to ft. <br /> OBSTRUCTIO WDEBRIS/FILL <br />� WELL OWNER'S NAME Obsiruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> %�_,_ - <br /> Well owner's mailing address if different than property owner's atldress indicated above. Type of Obstruction/Debris/Fill -1'��"�F lt- �"�/./��l � ,a� � <br /> Obstruction/Debris/Fill removed? r]•Yes ❑ No <br /> PUMP / <br /> TY� �f!� /�.f i�]t..l <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,intlicate estimated tormation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � _ ,� ,�No Annular Space Exits ` <br /> '�...._-� ---=...! ,' � ; � <br /> ❑ Annular space grouted with tremie pipe <br /> ,".�1 <br /> ❑ Casing Perforation/Removal <br /> in.from to k. ❑ Pertorated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type ot pertoretor <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> B�,,.h,���,�1�� ,��. � r,. '� , <br /> Grouting MateriaV"��� - "ffom to�_ ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> t <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS - <br /> Other unsealed well or boring on property? ❑ Yes No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> i <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 ot my knowledge. <br /> Di>I�T S'T�DGLA W'ELI. DRILLIAIG Ci;. , ilvC. "1.%1!'t <br /> Contrador Business Name > � License or Regisfrefion No. <br /> "�i� %' / "` ��� �/ � <br /> Authonzed Representative Signatuie` Date <br /> �.- <br /> � ��` <br /> .1:� � <br /> LOCALCOPY H <br /> 12 6 5 6 5 Name o/Person S@aling Well or Boring <br /> .HE-01434-02 10/95R <br />