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�. _ - <br /> Minnesota Well and Boring H 3� 13 9 <br />�� WELL OR BORING IOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. <br /> �., �o�n�Y Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No. <br /> s=, ;M Minnesota Statutes.Chapter 103/ or W-series No. <br /> � �ij �Leave blank if noi knownl <br />�.�� Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br />� '- -�� -^ r;� ; or Bonng Consiruded <br /> �a li7 �,4 �� �,4 -�. } - � � <br /> Numencal SVeet Address or Fire Number and City of Well or Boring Location <br /> } r_.� - } �' <br /> � �1/1LA G�..� if.y Depth Before Sealing �py ft. Original Depth �S � j ft. <br /> LiJ•�1V a7[ii'14 1W �.. <br />� Show exact location of well or boring Sketch map of well or boring StaUc Water Level ccurate <br /> in section grid with��X`. �,.� location.showing property lines. � <br />�� <br /> Is�, N ,v_ ��oads.and buildings. ❑Approximate ,=F� <br /> r�-:' '� �a: <br /> i i i _ � L, <br /> � � � �'y "` � Single Aquifer ❑Multiaquifer -��L_fl. � below above land surface <br />� •� i i i i r.. <br /> r„ _�_ _�_ _i_ _i_ � CASING TYPE � <br /> c ' W i i i i E <br /> s.��� i i i i 5'S <br /> 4.: _�_ _y_ _r_ _�_ <br /> i � i � � Steel ❑Plastic ❑Tile ❑Other <br /> 5 mile <br /> _� � � I_ � � <br /> I I I I <br /> .j� <br /> S - Screen irom� to srL=� fl. Open Hole from to it <br /> �--t mi�e-� �� OBSTRUCTION/DEBRIS/FILL <br /> i�� <br />�`- PROPERTV OWNER'S NAME ❑Obstruction ❑Debns ❑FIII " <br /> F <br />�� 471-9658 � <br /> �__i: .�a� �'�.�1 �l <br />��. J Type of debris/obsiruction �v� O�{-� � �-�. � j ; (%1�, � <br />�s''� Mailing Address d different ihan property address mdicated above. <br /> - Obsiruction/Debris/Fill removed7 Yes ❑No �'y <br />� > _.h.�i 1 � <br /> PUMP <br />� � <br /> r� <br />�' ❑Removed Not Present ❑ Other <br /> CASING <br />.�� GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br />�'. Diameter Depth Set in oversize hole? Annular space initially grouted7 <br /> If not known.indicate estimated formation log from nearby well or boring. <br /> k. : �,��, ���ccc---VVV <br /> ' �in.from {��� to ��ft. ❑Yes ,�y No ❑Yes ❑No ❑Unknown <br />� 4 �� <br />�;-s�;. in.from to ft. ❑Yes ❑No ❑Yes <br /> ❑No ❑Unknown <br /> 4;;'; <br />�',. in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br />�� <br />�b;� No Annular Space Exists � <br /> p � Annular space grouted with tremie pipe <br /> �N, e� <br />.��,'__- ❑Casing Perforation/Removal <br /> s <br /> in.from to fl. ❑Perforated ❑Removed <br />� <br /> W:.;s <br /> in.from to ft. ❑Perforated ❑Removed <br />�� �"� Type of perforator <br /> ❑Other <br /> � <br />�'�� GROUTING MATERIAL <br />�i:'I <br /> � -. <br /> Grouting material y}����(ti��,�r=��from �_to �}�, •, ft. yards 1 ti bags <br /> r <br /> from to fl. yards bags <br />�'����' REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING - <br />?'r'` <br /> from �o it. yards bags <br /> : Gs�outCed �i" �aell 2�3' Cieep - k <br />'��,^�.' 'ZO "1�i•.n s�� - trom to ft. yards bags _ <br /> w� a <br />��?�� LL IIJ� t�J�tOI�iLCy UNSEALED WELLS AND BORINGS <br />�.T. 2 � 'I...t�..«f �,.{�, � �� ��� TM� Other unsealed well or boring on property7 ❑Yes � No <br />�4-�,� 1LSW1 a�..�7 2..��Y. :. <br />�£:,;� LICENSED OR REGISTERED CONTRACTOR CERTIFICAT N <br /> s�"' <br /> This well or boring was sealed in acwrdance with Minnesota Rules.Chapter 4725.The informa[ion contained in ihis report is <br /> � � irue to ihe best of my knowledge. � <br /> a .y; . :�.'c <br />� �;��� ` �OR1 St0�0�.8 �@.�.1 ��1� L`�.s �I3C. ��17� � <br /> ': a ,�,a.:;,,. "' <br /> � m .�:.� � x '� Contractor Business Name License or Registration No. <br /> w �`4 i :�',s��.: _ d a �. '.. , i'.:��--- � <br />� �.-�_..�-'�! �-_� '�. ��-z�-9� <br />� on e senta6ve S�neture � Date <br /> LOCAL COPY �„I 7'j,*� j�;�e <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-07 <br />