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Minnesota Well and Boring ?;
- WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 3 l 0 4 9
� CountyName WELL AND BORING SEALING RECORD M��nesota u��q�e No.
Minnesota Statutes.Chapter 103/ or W-series No.
p N iLeave blank if nol known� .>
\. �
Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approxima�e Da�e Well -
,� ` or Boring Cons�ruded
��a ��a ��a � �� �'� S
�� Numerical Sireet Address or Fire Number and City ot Well or Boring Location ,,,
�,.. �( I
�, r r^ � �� � Depth Betore Sealing � � ft. Original Depth ��` (='�' it.
�`. Show exact location of well or boring Sketch map of well or boring Stahc Water Level ❑Accurate
in sec�ion grid with��X��. loca�ion,showmg property lines.
N �tf roads.and buildings. �Approximate -
,��.� i � i i_ :� , /
K ; -i i- -�- -i [
& , Single Aquifer ❑Multiaquiter '��; fl. � below above land surface
° i � i i � �" � l�
-�- -�- -�- -�- � CASING TYPE
��� W i i i i E � '
k /
I 1 I I �yj
4 � -i- -�- -r- -r � L
�:_: i i i i � � f �Steel ❑Plastic ❑Tile ❑Other
:;mile
F" _i I I i_ � )
_ _ '_ _ _ _I f
�: S "' "��-�.,, � i/ Screen trom to ft. Open Hole from to ft
N-�mile----� / OBSTRUCTION/DEBRIS/FILL
�`=;' �Obstructlon ❑Debris ❑Fill
y, �� PROPERTY OWNER'S NAME
3
Y ` ..,_ '..,. .: .F.�;,� ;;.�: ✓ TYPeo(debris/obsiruction + It�..3r�:,•'fJ 1 fY:,, �-�, � L.,_�;�. C. � �f=. �l- F, .
Mailing Address rf ditfereni ihan property address indicated above. a
� Obstruction/Debris/Fill removed7 Yes ❑No =
�e^a't'T-(.. ;`.P' . . PUMP
�.S_.
�
� � ❑Removed o�Present ❑ Other
� CASING � �
HARDNESS OF ��
� ; GEOLOGICAL MATERIAL COLOR FROM TO
FORMATION
`' ' Diameter Depth Set in oversize hole? Annular space initially grouted7 F'�
��: It not known,indicate estima�ed formation log from nearby weli or boring.
�F� � ; q
in.from �to �� k. ❑Yes QQ�Io ❑Ves ❑No �(lnknown
/-
�-����'�� in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown ��''
�;=
�;:�:" in.from ro fL ❑Yes ❑No ❑Yes ❑No ❑Unknown
u��::
��;;; METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�-� �[l�lo Annular Space Exisis
� ` "\
� ❑Annular space grouted with tremie plpe �. .�: �,� ,� {�-s�- ;'�..,�- �.3
�€� �� ❑Casing Perforation/Removal "�
F fip
E+��. ��
� �
� in.from to k. ❑Perforated ❑Removed
�-,; �
� ���s in.from to ft. ❑Perforated ❑Removed
�,,.�:�: '�
��'`�- Type of perforator
r
����- ❑Other '�
�,,;
�fi:.; GROUTING MATERIAL
<�
�`� 'r;
tif:, �
.�s
4ri^p� Groutingma�erial���i��Y1�t.:d�! �f from ��i to �,�k. yards � <� bags '
c,:' °[
k a;p ..
�: from to ft. yards bags �,a
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING �'
�
from to ft. yards bags
~ " � �
��' � �,�.`��� � �,
y-n,� " ,t ' from to ft. yards bags
€z� �� �
K„w.� ( � \�, � �.�,V� UNSEALED WELLS AND BORINGS t�t� � .. , � _ �`,_f �f : , `�
�. .)cK:+C� Y uo G�:�
Other unsealed well or boring on property? es ❑No ,,�
rr U�� � LICENSED OR REGISTERED CONTRACTOR CERTIPICATION
. C C�G. vSIvE
�-� This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is �
�t
�i„�� '` � r true to ihe best of my knowledge.
��''MC��:V �i f:,i/�l ��!�1 S 7
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�ix ��1� .� f,'�� � , ;��� ContractorBusinessName Licens�eorRegistrationNo. 3�
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�- { 4;. �=����-� �l- � �
�`�.�li,f C� �n 5 l ��� l y*� 4 y-�ri �.
` -� Authorized Re resentative Signature � Date
. \ • \ � �/ ,�,C.� �--'
LOCAL COPY H �?: 1;.,r� r `�++.", �
t,;
Name ol Peison Sealing Well or Boring
H601434-01 �