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