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Minnesota Well and Boring 44840 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH SealingsNo. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Minnesota Statutes.Chapter 1031 or W-series No. !i:', . <br /> r'tel ane j.3 i n (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm. •lg.) Date Sealed . Approximate Date Well <br /> rc' i€J 117 f,= -4 1a 01" 'ti' 1ra 1 iVQ aQV 1! Q� or Boring Constructed <br /> la <br /> Numerical Street Address or Fire Number and City of Well or Boring Location t <br /> t:;.• Orene 4�:a.aC.i Cl. Y:C',d mss. Orc1io ddl.,...,.w'9 depth Before Sealing .. 7 tt. Original Depth 5 7 it <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level Accurate <br /> in section grid with"X: • ation.sh ,, rro�operty lines <br /> N roadsowingbuiltiir'gs,. 0 Approximate <br /> ,�,f4 b e <br /> Single Aquifer 0 Multiaquifer ft. below above land surface <br /> - —L CASING TYPE <br /> W ; E <br /> t hmik� Steel 0 Plastic 0 Tile 0 Other <br /> I <br /> a <br /> S Screen from `�1 to 5 7 ft. Open Hole from to ft. <br /> t mil J'.. --....t • i• 1. f e'f p <br /> OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME / lbstruclion 0 Debris 0 Fill <br /> %,jj_c I.xu''l A t <br /> Type of debris/obstruction ott4'"- <br /> Mailing Address if different than property address indicated above. <br /> Obstruction/Debris/Fill removed? 0 Yes 42 No <br /> PUMP <br /> ❑Removed P.lot Present 0 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. r <br /> drift 0 <br /> 57 in.from to i) ft. ❑Yes ..)glo 0 Yes ❑No 0 Unknown <br /> in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> in.from to ft. ❑Yes 0 No 0 Yes 0 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 ft. 0 Perforated 0 Removed <br /> - in.from to ft. 0 Perforated 0 Removed ' <br /> Type of perforator - <br /> ❑Other 1 <br /> ' GROUTING MATERIAL <br /> i t <br /> Grouting material A1' f Cj1neWl from d to 57 ft. yards Zbags <br /> from to - ft, yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING . <br /> from to ft. yards bags <br /> Grouted 2" veil 57' deep from to ft.• yards bags <br /> 2 baps cement UNSEALED WELLS AND BORINGS <br /> 4Ibs bentonite Other unsealed well or boring on property? 0 Yes o <br /> 2mem labor, rig & t grout }gam LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> pump 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 /> DLi ''.:•:;:01".:01..i 11‘1"241.1.: URI:LU G U>., I .I. d rt 2 <br /> Contractor Business Name License or Registration No. <br /> � 1I-13 <br /> 'utho or;-esentative Sig'ha r e Date <br /> LOCAL COPY H 44840Jim Antonson <br /> Name of Person Sealing Well or Boring <br /> HF-01434-n1 <br />