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Mltltt.solE Wee and 8wnq <br />RL Olt MOIr/OIOCATION MINNESOTA DEPARTMUx ENT HEALTH Seawg No <br />sou 429 0 3 <br />courant Name WELL AND BORING SEALING RECORD --oast ore No <br />Minnesota Statutes Chaplet In a% <br />Tasmsh,p Name Tuwnsha, No Range No Section No tg I Date Seaierf Appronmate Date Well <br />11,molon,sin <br />Cris t< 11 I s - - rri I- I t-I `1 , &,r� q eu s,nMted <br />Nutnetr al Slreel Address or Fire Numbet and C,ly „f Well or gor,rg Lncal*. <br />- t' i't1!•r � T i.A)w 16U. lTtxk" f`rl. <br />Depth Before Sealing _ ( J L h <br />` <br />OrgnatDepth <br />Show exact lofalrerl of "I w boning <br />S4etch reap of well or boring <br />Slat•[ Wale, Le l Accurate <br />n function grid with X <br />location showing property Ines <br />❑ Appro■—ate <br />N <br />roads and budd.ogs <br />Single Aguder Cl Mulbagullec <br />r_ n -.— -- below above land surface <br />r � <br />- ' - - • - -'- <br />CAfIM TYPE <br />iIV r <br />r I � <br />r <br />t.Y <br />Sleet ❑ Plastic ❑ Toe ❑ other <br />I� <br />r r <br />r V' <br />S <br />r. <br />Screen from to fl oparl Hole from to n <br />ODiT11UCT10WDEDIMlIle141 <br />�1 <br />❑ Obstr,rctron ❑ Debris El Fill <br />wTDPE1m OWNER'S NAME <br />Type of debrwobstructron V v j r <br />Mailing Awhess d ANetenl than property addess vndrealed borne <br />ObelnrcftOrJOebrrLftN rwrwved' Vex ❑ No <br />li.jl''. imtic-s Ridge <br />PUMP <br />Rim Prairie, MN.55�0 <br />❑ Removed Not Present ❑ ofMl <br />CASM <br />tee/ Depth Set in overslts hole' Annular space ntraNy grotrsed� <br />from - to �' IF ❑ Yes ko ❑ Yes ❑ No n UnluWal <br />n from to If ❑ Yes ❑ No ❑ Yes ❑ No ❑ unknown <br />_ in from to If ❑ Yea ❑ No ❑ yes ❑ No ❑ Umnowl <br />OEOLOOICAL MATUMAL <br />OOLOII <br />f n OF <br />NI011 <br />TO <br />S no U,nwn, ndcaN esbruted IomWgn tog from nearby ImIl or bang <br />O <br />Ilse <br />— <br />ISTTTOO USED TO SEAL ANWAAM SPACE WTWM S CASt110S. ON CASH AND 0011E "OLE: <br />No ArnlAar Space Exalts <br />❑ Annular space grouted with trwtue pipe <br />❑ Cal ng PeAaatnrvRartloval <br />n from to n ❑ Pwtwatw ❑ Removed <br />in from to n ❑ Pookmm ad ❑ Rwnoved <br />Type of <br />' <br />t <br />.• <br />perforator <br />❑ Ohw <br />— U E <br />6 <br />ONOUTNO MATE1MAL <br />Groutng material + ` _ Yrom L _ to n yard bimp <br />from to n yards begs <br />MNAMfS. WUPCE OF DATA. D/PCMTXS 0 SEAh1M1: <br />From to h yards page <br />30bw <br />from to h yards begs <br />IMgEAIED WELLS AND OOIMIOS <br />2 men labwE Sig i cement gI pW <br />unsealed aa bang on property' Ores <br />NSED 011 IIEOSTEIIED COMTIIACT011 C911111`1111116ADMI <br />LICENSED M <br />This wee or boring was sealed in accordance with Mwnesola Rules Chapter 4725 The information cor•taned in fhrs ,epon .s <br />True to the test of my knowbdge <br />14 d: :11i11 lLr'. rl►i: i.[ r U U dAINC c'l <br />Cont,acfo, Business Nance Lcense or Reg stratio n No <br />------9-1 "3 <br />1 prpsPnlA 11Y• yn3lu,P ()Jm <br />_� ---- - - - --- ---- <br />H 42903 <br />NAmr• ::r Person Seal.g Well or liavg <br />HE-01a11 '� <br />