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Minnesota Well and Boring
wELL oR eoaw��oCnTioN MINNESOTA DEPARTMENT OF HEALTH Sealing No H 121718
�����YName WELL AND BORING SEALING RECORD M���eso�a u��q�e No
� Mrnnesota Statutes. Chapter 103/ or W-series No.
�� �4✓' Il F=tvf blank i�nol known�
Township Name Township No Range No. Section No Fraction�sm. �Ig.) Date Sealed Approximate Date Well �
� �� _, � '" or Bonng Gons�ructed J � ..,.�
(�;:� ,�, �„ �,., �„ 1 d� � _
Numencal Street Atldress or Rre Number and City ol Well or Borng Localion .� , / � (
� +`� � � ��`...i,. . � , ;"� -.�- Dep�h Before Sea6ng � "� f�. Original Depth � � �� ft
Show exact location ol well or bonng Sketch map of well or boring Static Wa�er Level �Accurate
in sedion gnd wdh�X�� location.showing propeny hnes.
N roads.and bwldings ❑Approximate
I
-;- -;- -;- -;- t � �,)� �� �1 � �� � X
� i �ngle Aquifer ❑Multiaqwfer ft. below above land surtace
i i i i *i
W i i � i E rk� CASING TYPE
� � ..i
i i i i �
-- -�- -r- -r � J,� ,�(
i � i i r L�TS�eel ❑Plashc ❑Tile ❑Other
m�ie s ' t
_ ! !_ _�_ � _ 't
�_ _ _ _ _
S . Screen from to ft. Open Hole from to ft.
���mile--�I �. OBSTRUCTION/DEBRIS/FILL
� �Obs�ruc�ion ❑Debns ❑Fill
PROPERTY OWNER'S NAME
_�, , ; � � j . i � r
Type of debns/obstruclion
Mading Address d ddferent ihan property addre�ss indicated above.
Obstruchon;Debris:Fill removed7 �Yes ❑No
PUMP
\.
�Removed ❑Not Present ❑ Other
CASING
��- GEOLOGICAL MATERIAL COLOFI HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space initially grouted7
I(not known.indiwte estimated formahon log fmm�earby well or boring.
��� � in.Irom � to � � � tL ❑Yes L7No ❑Yes ❑No �Unknown
in.trom !o fl. ❑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 pND BORE HOLE:
�`'No Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casmg Perforalion/Removal
in.from �o fL ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of perforator
❑Other
GROUTING MATERIAL
{ r �'`
Grouting material ` �� � � , irom ro � � ���� ft. yards `� bags
from to ft. yards bags -
REMARKS,SOURCE OF DATA.DIFFICULTIES IN SEALING
� from to ft. yards bags ,�
\ �� . �'� t
from to ft. yards bags �
� ��'�._ UNSEAIED WELLS AND BORINGS y...;: . ., �-I �
�. � Other unsealed well or bormg on property? ,[Y Yes ❑No 1,•-.:- � ��
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules.Chapter 4725.The in(ormation contained in ihis report is �
� true to the best of my knowledge.
�/r � � l� C' � �°1,e..�j �/
Contractor Business N�rne License or Registration No.
..� �.,ti L,��_�� � � •- '_, .
�� Authorized Re esentafive Signature Date
LOCAL COPY A/ � ' ' � �V � � � , J �
. � 1 f�1 7�8 Name ol Person Sealing Well or Boring
HE-01434-01 ..