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Minnesota Well and Boring <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEAITH Sealing No. H <br /> CounlyName WELL AND BORING SEALING RECORD M���eso�a u^�Q�e No. .;� <br /> �Zj��l,j} Mmnesofa Statutes.Chapfer 103/ or W-senes No. /'� <br /> ILeave biank�I noi knownl <br /> Township Name Townsh�p No Range No SecUon No Fraclwn(sm. •Ig) Date Sealed Approximate Date Well <br /> q � or Bonng Consirucled <br /> t��)n� ! �7 .4✓ �f ���--5%l�a/U'ia � <br /> Numencal Slreet Address or Fve Number and Gly ol Well or Bonng Locahon �/� � y/.'��'�� � i <br /> 1375 P�rk Driv+E: vlflnf:� ��• �J✓`6'i Deplh Be�ore Seahng �,L� fl Ongmal Depth `-�' f� <br /> SFaw ezact bcatan ol wefl or bonng Sketch map of well or bormg Slatic Water Level Acwrate <br /> m secLon gnd wdh�'X-. ' IocaUon s wmg propehy hnes. <br /> � �oads.and bwldmgs. ❑Approwmate <br /> -- -;-N-r- -- f <br /> � � i ` � <br /> ��i o �/� <br /> � '' Single Aquifer ❑Multiaqwfer yl1—fl. � below above land suAace <br /> i i i i --��- � <br /> -i- -�- -i- CASING TVPE <br /> w i i i i E <br /> - -�- -r- -r <br /> i i i ,� y ` � �"�^.,f � Sleel ❑Plashc ❑Tile ❑Olher <br /> , LJ <br /> -- - i_ � � <br /> i- --- -� / �f,l <br /> I S ��I ? (;.�. 3 Screen trom —�— b —L� fl. Open Nole from to it <br /> �""'k� OBSTRUCTION/DEBRIS/F�LL <br /> ObslrucUon ❑Debris ❑Fill <br /> PROPERTV OWNER'S NAME <br /> Dic.'� & P r�attct; 1,�s�. PrP� 9-- Ji� <br /> Type of debns/obstruction <br /> Maihng Address d different ihan property address�ndicaled above. <br /> Obsiruction/Debns/Fill removed� �es ❑No <br /> 8�48 Holaxnb Sriciqe R� e1�MP <br /> 4G�-993-�]92 ��lthare�'�, C�. 3C;L(;� --- <br /> emoved ❑Not Present ❑ Other���� ���� <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Sel in oversize hole7 Annular space iNtially grouted? - <br /> II not known.indicale estimated torma�ion log irom nearby well or boring. � <br /> // <br /> � in.from � lo � ft. ❑Ves �'No ❑Yes ❑No ❑Unknown <br /> - " �c �- i._� _>/) <br /> m.trom to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unk�own <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �o Annular Space Exists <br /> ❑Annular space grou�ed with tremie pipe <br /> ❑Casng PeAoration/Removal <br /> in.irom to fl. ❑Perforated ❑Removed <br /> in.from to tt. ❑Perforated ❑Removed <br /> Type o(perforator <br /> ❑Other <br /> GROUTING MATERIAL - <br /> / �� <br /> i <br /> Groutingmaterial�/Uj�_�TI ���I�1�Irom _�_to fl yards bags <br /> from to ft. yards bags <br /> REMARKS.SOURCE OF DATA,D�FFICULTIES IN SEALING <br /> (rom to ft. yards bags <br /> irom to ft. yards bags <br /> UNSEALEO WELLS AND BORINGS <br /> Other unsealed well or boring on property7 ❑Yes ❑ <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or bormg was sealed in accordance with Mmnesota Rules,Chapter 4725.The information contamed in ihis report is <br /> true to the best of my knowledge. <br /> DC�A1 S`�:tiJt)C:L� 't�..I. IJ�1.itL�I:1tiG CG., Ihit:. G!1%�: <br /> Conhactor Busrness Name L�cense or Reg�strahon No. <br /> � r'� <br /> , �, /`�' �j f._, ;� <br /> t .�f?epr2senta6ve Signature` ��� Da�e <br /> _.� �J <br /> ( . f:-ti ,/-1 ��-� �r= �:�J�'l <br /> �,Q�.�i,�;;f1)Ff�''(( � Name ol Person Sealrng Well o�8onng <br /> HE-Ot434-01 <br />