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Minnesota Well and Bonng <br /> WELL OR BORING LOCAT�ON MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> CountyName WELL AND BORING SEALING RECORD M���eso�a u��Q�e No. <br /> �'^��'�-� Minnesota Sfatutes.Chapter 1031 or W-series No <br /> ILeave blank il noi known� <br /> Township Name Township No Fange No Seclion No Fraclion(sm. •Ig.) Date Sealed Approximate Date Well <br /> / j ,-�.�, j,+�/ or Bonng Cons�ructed <br /> c�r� i t7 z3 0� ��14����;���,a � f <br /> Numencal Slreet Address or Fve Number and City of Well or Bonng Localion ,-��� f <br /> j.�!5 t'ark Dr_ive Ur�C.7� �11. �5��f�� Depth Before Sealing ��",'-� It. Onginal Depth h. <br /> Show exact localwn of well or bonng Sketch map of well or boring Static Water Level �Accurate <br /> �n section gnd wdh��X�� sy lo�ca�ion.sTi wmg propeAy hnes. <br /> t �oads.and buildings. ❑Approximate <br /> -- -�-N--- -- C � ) <br /> i <br /> �y Smgle Aqwter ❑Multiaquder fl below above land surtace <br /> i i <br /> � _�_ -i_ ,,� CASING TVPE <br /> W ' ' E J�u. <br /> � � i � o <br /> _�_ '�_ _r_ ❑Other <br /> i i i m.� " S�eel ❑Plas�ic ❑Tile <br /> , � ,_ 1��;,t � �,�. c_ <br /> -;- - ,- --- -, <br /> ��T�� f � - <br /> S MMC.1.� � Of �$ Sueen Irom � ��I�� lo � "� '� f� Open Hole from lo fl. <br /> � �'"'k� OBSTRUCTION/DEBRIS/FILL <br /> ❑Obs�ruclion ❑Debris ❑Fill <br /> PROPERTV OWNER'S NAME <br /> Dicis & Peggy Hatch ,�,,! , , <br /> Type of debris/obstruction <br /> Maihng Address d dAferent ihan p�operty address indicated above. <br /> Obstruc��oNDebns/RII removed� ❑Yes ❑No <br /> C7L.'�!U HQ�L:LitiJ BiI1C� PUMP <br /> R1tF�Z'E?t�� Cx3. 3!;:c(;2 <br /> t��J4�-�i7�—jt t7� ❑Removed NotPresent ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOH MARDNESS OF FROM TO . <br /> FORMATION <br /> Diameter Depih Se�in oversize hole? Annular space irnhally grouted7 <br /> If not known.indicale esUmated IormaUon log from nearby well or bonng. <br /> � � � in.from ` '� to ��J fl. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> t i '� �'�.:1 <br /> in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br />�, m.from to tt. ❑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 /> ❑Casmg Perforation/Removal <br /> in.from to fL ❑Pertorated ❑Removed <br /> m.irom �o ft ❑Perforated ❑Removed <br /> Type o(perforator <br /> ❑O�her <br /> GROUTING MATERIAL <br /> (% <br /> Groutingmaterial �=�'� `' � `��"`�l+drtl� '�-� to �'-1��� it. yards -��-, bags <br /> from to ft. yards baqs <br /> � REMARKS.SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> from to ft yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Ves No <br /> LICENSED OR HEGISTERED CONTHACTOR CERTIFICATION �" <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained m ihis report is <br /> � irue to the best of my knowledge. <br /> DU[3 :'IC7DC�I.T+ WEI�., D�II.i,ING C�,, INC. 2717� <br /> Confractor Busrness me 3 �;. License or Reg�sfra6on No. <br /> � <br /> �_,r,..�- _.. <br /> �, .,� �/- i' i% <br /> � uf nz epresenfativeSignature� Date <br /> _r <br /> u �..,� . /s,, �;'l. �c� i 1.::C.J�i <br /> i������7� n ����7 Name o!Person Sea6ng Well or 8onng <br /> �� HE-01434-01 <br />