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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL OR BORING LOCATIONSealing No. H 151593 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> 1 ` Minnesota Statutes,Chapter 1031 or W-series No. <br /> / , 4; t�. (Leave blank it not known) <br /> Township Name Township No. Range No Section No. Fraction(sm.-w ig.) Date Sealed Date Well or Boring Constructed <br /> t ,v <br /> ,4 `73/5-; /170' 5 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location I <br /> i t # > Depth Before Sealing ft. Original Depth I f rte- ft <br /> Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X'' location, showing property �gl`Single Aquifer ElMultiaquder <br /> lines,roads,and buildings. /WE <br /> N WELL/BORING Measured ❑ Estimated <br /> -r- — , , , _ -1 , Water Supply Well LIMonit.Well �,( <br /> ❑ Env.Bore Hole ❑Other ft. )(below Ill above land surface <br /> W r-_-l----1 E ��/� Il/c- CASING TYPE(S) / <br /> -'r---;----, V/ (Steel ❑ Plastic Li <br /> LIOther <br /> { I j tc mile <br /> --_�_-- i- CASING <br /> Diller Depth Set in oversize hole" Annualar space initially grouted? <br /> mei., n.from f to I y ft. ❑ Yes ,[,No ❑ Yes [1] l <br /> No �J Unknown <br /> PROPERTY OWNER'S NAME I in.from to ft. ❑ Yes r❑No ❑ Yes ❑No/'❑ Unknown <br /> Property owner's mailing address if different than well location address indicated above in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> )J ( ±G A- / - . '- ti SCREEN/OPEN HOLE <br /> 14\ji O ! L s A Cs I i-s, , ? Screen from to ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address If different than property owner's address indicated above. Type of Obstructions(Describe) t r/Cl t f. I p!!�' <br /> Obstructions removed? ,'Yes ❑ No Describe t.1ll f1 " //( +'_7{ <br /> fl(< <br /> PUMP TTTTTTiiiiii <br /> Type S t4 hOlt16 i It <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO XRemoved ❑ Not Present ClOther <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. ET OD 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 ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S)�J1 <br /> c' ( <br /> ,1/1 'Ie _, <br /> Grouting Material Irom to J17 j <br /> (.x`-,shf <br /> . yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to— ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> 1 /I / /e/' ir6e+111 Other unsealed and unused well or boring on property? ❑Yes )No How many? <br /> Yti/ Iii6e OR REGISTERED CONTRACTOR CERTIFICATION <br /> /i cl4",ihy'} f) • <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> �,1// ( true to the best of my knowledge. <br /> Contractor Business Name License or Registration No. <br /> • <br /> t - .. <br /> Authorized Representative Signature Date <br /> LOCAL COPY <br /> H 151553 Name of Person Sealing Well or Boring <br /> HE-01434-04 8/98 R <br />