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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 2 9 0 4 2 `
�o��lY Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No
Minnesota Statutes.Chapter 7031 or W-series No.
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Township Name Township No Range No. Section No. Fraction�sm. •Ig.) Date Sealed Approximate Date Well
�,.,1 �, _.„, /' �� ,,,„, = `� or Boring Constructed � � Z3�y
,�_If/C.� C.. ��a �ia �ra ��'' . f !
Numerical Street Addres;or Fire Number and City of Well or Bonng Location .y ^7. � \ �
" ' � I � � d �
�� '..;/�_`,;V;� �'rv% � -� ✓Z.,n�,: Depih Before Sealing -�` fL Original Depth ' tt.
Show exact location of well or boring Sketch map of well or bonng StaUc Water Level 1�Accurate
�n sec�ion grid wi�h�'X��. loca�ion.showing prope�y lines.
N roads,and build�ngs. ❑Approximate
�i w�
1 I I I h / X �
-� -�- -�- -� 1j"� � i- � �Single Aqui�er � q � �1
❑Multia wfer ft. below above land surface
i i i i -
_i_ _�_ _i_ _i_ CASING TYPE
W � � i i E ��
i i i i
_i_ _�_ _r_ _i_
� � i i � � f � �Steel ❑Piastic ❑Tile ❑Other
'o mile ��•^..` ...
� � i i t V .S
-� -�- -i- -i- � � � �,,.....'" 1� C=
s
S ' �.;.,. Screen from to ft. Open Hole from to ft.
�-imile--►I 1 OBSTRUCTION/DEBRIS/FILL �
PROPERTY OWNER'S NAME ❑Obstruction ❑Debris ❑Fill
n
� l.l 7 " � n ����; ��'.:t.� '" 1\.��,`^�-.�1...._
�\� � Type of debris/obsiruc[ion
Mailing Address if ddferent than property address indicated above-
Obstruction/Debris/Fill removed? ❑Yes ❑No
PUMP
❑Removed �ot Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space initially grouted?
tl not known,indicate estimated formation log irom nearby well or boring. �, ,.�
� � in.from � to � � � fl. ❑Yes L�`Wo ❑Yes ❑No Y1 Unknown
/p�
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to fL ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to fl. ❑Pertorated ❑Removed �,
Type of perforaror
❑Other �
GROUTING MATERIAL
� ��, �.�
Grouting matenal � ''�� �� from '�'� to � ' ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
, r r
� i ( 1
� j f i' ..... y1..:.
" � - from to ft. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? �Yes ❑No �`�-%�-'�� �. �: �!�^�, �'� ��--i(:. � �
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed m accordance with Minnesota Rules,Chapter 4725.The information contained in this report is
true to the best of my knowledge. _
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Contractor Bus�ess Name License or Registration No.
; ! � "S.
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Authorized epresentative Signatuie Date
LOCAL CCUPY �„+ �l .�< ;i',✓�� `.� v � . . (� �I ..l
2 g O 4,Z Name o/Person Sealing Well or Boring
� HE01434-01