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Minnesota Well and Boring H 58024 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> HMinnesota Statutes.Chapter 103/ or W-series No. <br /> `- ir'N h (Leave blank if not known) <br /> Township Name ITownshipNo. Range No. Section No.IFraction(sm. .1g.) Date Sealed Approximate Date Well <br /> .\ or Boring Constructed <br /> I/4 t/4 I14 } <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> - j - <br /> Ll j �, i Depth Before Sealing ft. Original Depth ft. <br /> yam' _.. ��,,,✓ t � <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level 9,Accurate <br /> In section grid with"X location.showing property lines. <br /> N ( roads.and buildings. ❑Approximate <br /> I I / r 1 <br /> LASingle Aquifer ❑Multiaquifer ftbelow above land surface <br /> � i ! <br /> _I_ _ _ _>__ _I_ y CASING TYPE <br /> W E <br /> I I I I T <br /> I I <br /> iM ( ,Steel ElPlastic ❑Tile ElOther <br /> h m <br /> I I I I <br /> S `–y -fScreen from to ft. Open Hole from to ft. <br /> I mk — <br /> ' �I ! � OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME Obstruction ❑Debris ❑Fill <br /> Type of debris/obstruction <br /> Mailing Address If different than property address indicated above. <br /> Obstruction/Debris/Fill removed? a.Yes ❑No <br /> PUMP <br /> 1 r Removed ❑Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring. \ <br /> in.from to ft. ❑Yes LINo ❑Yes ❑No 3,Unknown <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 /> 9 No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to K. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> • <br /> Grouting material 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 /> V 1 <br /> from to h. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> t Other unsealed well or boring on property? {..Yes No <br /> I <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 <br /> Contractor Business Name License or Registration No. <br /> Authorized Representative Signature Date <br /> LOCAL COPY H <br /> 58024 <br /> Name of Person Sealing Well or Boring <br /> HE-01434-01 <br />