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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEAI.TH Sealing No. H 2 9 0 4 4 ��
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�o���Y Name WELL AND BORING SEALING RECORD M���esota���q�e No ,��
Minnesota Statutes.Chapter 7031 or W-series No. '�
����� ILeave blank if nol knownl
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Township Name Township No. Range No. Section No. Frection(sm. •Ig.) Date Sealed Approximate Date Well `4
� y �F, y �� ��„ or Boring Consiructed / '' �� �
!C�� •� �1 .. ��a �ra �ia ? ... ! ,�� : V .� �
Numerical Street Address or Rre Number and City o(Well or Boring Location � ,-r�y�� � �
s"' � �+ ' Depth Before Sealing � � � (L Original Depth L' C� ft. �
Zf:. �Ae.r:� -'r � �.
Show exact location of well or boring Sketch map ot well or boring Static Water Level �Accurete 1�
in section grid with��X'�. bcation,showing property lines. �
roads.and buildings. ❑Approxima�e -�.�
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i i i i �-.,_..._.-
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� Single Aquifer ❑Multiaquifer ���-' fL � below above land surface
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-i- -a- -i- -�- .,,` CASING TVPE �
W i i i i E ,`�
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-�- -,- -r- -�- .�r� �
i i i i ..� l 1 � Steel ❑Plastic ❑Tile ❑Other �
n mile
_i i i i_ � '.� L.�^r� ..-�� .
i_ _ i_ _i _ _i � .,�
.'� ' �
t� � j Screen from to ft. Open Hole from to ft. _�Y�
�7 mile �
� L._�', OBSTRUCTION/DEBRIS/FILL
PROPERTY OWNER'S NAME �Obstruction ❑Debris ❑Fill �
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r; y�,/t �� {.� ✓ F�J �� � �ti.i � � ��i_t� � �( ��E�`��' rr ��� ` iJl.���i� �
'� �! Type ot debris/obstruction - - .y'
Mailing Address it ditferent ihan property address indicated above. �:.
Obsiruction/Debris/Fill removed? �,,Yes ❑No �
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: �
- PUMP
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t" �
,_? ,...,`M ` �
Y—�
- � Removed ❑Not Present ❑ Other
� CASING �
E - �
HARDNESS OF
¢=,�c. GEOLOGICAL MATEFIAL COLOR FORMATION FROM TO ,,�
Diameter Depih Se�in oversize hole? Annular space initially grouted? ''�
4� If not known,indicate estimated formation log irom nearby well or boring.
� �� s
°^� � / in.from `~' to � fl. ❑Yes �No ❑Yes ❑No �Unknown
��', � f
n=.
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
�
' in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
�.k'Y.
� � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�'�'�� �No Annular Space Exists
`;_:� ❑Annular space grouted with tremie pipe
s£;
❑Casing Perfo�ation/Removal
'?.;
�-. �
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in.from to fl. ❑Perforated ❑Removed »:�
in.from to ft. ❑Perforated ❑Removed ':
�� �
�i,%�
r.
��:`�' Type of perforator ���
F: 3'
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❑Other
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GROUTING MATERIAL
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- Grouting material '�. '���'�'��.5+-�t� from �' to � ' fl. yards � bags �
y..._
?.'�: 5.�
� from to tt. yards bags �
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���� REMARKS,SOURCE OF DA7A,OIFPICULTIES IN SEALING
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�,. irom to ft. yards bags
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" �--� �J� �t � C,`; � vt c..:
. -_.! trom to ft. yards bags �
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� ' , UNSEALED WELLS AND BORINGS ;�
�
1 �--� V e ' ' � � :� Other unsealed well or boring on property? ❑Yes No �'�
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� LICENSED OR REGISTERED CONTRACTOR CEHTIFICATION �,�
` '- This well or boring was sealed in accordance with Minneso�a Rules,Chapter 4725.The information contained in this report is �
��._ ' ���,� 'S`j ��r � �.'� �;t� L, true to the best of my knowledge. �
� _ 4 � , 1i r; 1'�, � jz/ �
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��,;� `; � . ��� Contrector Business Name License or Regisfration No. ��
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Autho zed Representative Signature -- Date �
� � 1 # �` 1�''
.. LOCAL COPY u . �� � � '�
�; n Name ol Person Sealing Well or Boring .
-�; HE-01434-01