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Minnesota Well and Boring Q � WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 5� ..J 8 t �: �o��Y Name � WELL AND BORING SEALING RECORD M��esota u��q�e No. . �("��1 , Minnesota Statutes.Chapter 703/ or W-senes No. (Leave blank if nol known) �� Township Name Township No. Range No. SecUon Na Fraction(sm. �Ig.) Date Sealed Approximate Date Well � � or Boring Constructed ( } � � � G � C�-,t,,r,, q`��.� '�,,. ',4 �. Numencal Street Address or Fire Number and City of Well or Boring Location � � � t"'�� L� �� "-�-•,_,� Depih Before Seahng �� ft. Original Depih �� fl. l Show ezact Ixation of well or bonng Sketch map of well or boring Static Water Level �.ccurate in section grid with"X��. � location showing property 6nes. _ N `-,/ � � f roads.and buildmgs. ❑Approximate �V '.{, , -� '�- "�" "� f'� _ � g q ❑Multiaquifer �tL � below above land surface i i i i (-'. .r ''�1 in le A uifer _i_ _�_ _i_ _i_ j r�- �r�"`. CASING TYPE W � � � � E }� �7i �• � � � � T � -r -7- -r- -r � � � � T � teel ❑Plastic ❑Tile ❑Other a mile � i i i � _i_ _ i_ 'i _ _- � . I J S r t Screen from� to � ft. Open Hole irom to ft. .+ N--t mi�e�I '� � � � OBSTRUCTION/DEBRIS/FILL bsiruction ❑Debns ❑Fill PROPERTV OWNER'S NAME _. '� . � r.—:�-� -� r� �� ( , � � �� `�� Type ot debris/obstrudion ��r/l,�f f(7 f�f�� s J�r � Mailing Address drfferent than property address indicated above. ObsVuctioNDebris/Fill removed?�Yes ❑No i /� PUMP � _,# ;-_ .�.;� i 4 � ❑Removed ot Present ❑ Other CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depth Set in oversize hole7 Annular space initially grouted7 If not known,indicate estimated tormation log from nearby well or bonng. � i/ s� .�- /'� '�in.from �-+� to � ft. ❑Yes �Vo ❑Yes ❑No ❑Unknown t,} � in.irom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �o Annular Space Exists ❑Annular space grouted with�remie pipe ❑Casing Per(oration/Removal in.from to ft. ❑Perforated ❑Aemoved in.from �o ft. ❑Perforated ❑f7emoved � Type of perforator ❑Other GROUTING MATERIAL � ... /�� 1 Grouting material/�� C'��✓��from (.J to �ft. yards �bags from to fl. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING from to ft. yards bags from to h. yards bags UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑Yes o LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is > true to ihe best of my knowledge. z 1 �: �1 I�ri ,�"1 C- �1 �}iFi';,',i: J�i��' GG, 1 � 7� Contractor Business Name J License or Registration No. / / / � � ..l�/ /��! - � �..q ��„L��-., j�� ... ��` ,..li� Aut zed�Representa6ve S�gnature Date LOGAL GOPY H V��V� �, T 1 ��, i � i` t._�,'�!� Name o/Person Sealing Well or Boring HE-01434-01