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WELL OR BORING LOCATiON MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
County Name WELL AND BORING SEALING RECORD M���esota u��q�e No. �
Mmnesota Statutes.Chapter 1031 or W-series No.
/� � � ILeave blank it nol known�
Township Name Township No Range No Section No Frachon(sm. •Ig� Oate Sealed Approximate Da�e Well
�`�,4 _ Y or Bonng ConsVucted / � ,;��,
1 ✓, y�.) �i4 �14 �ia . �.�., . _i'✓
Numencal Stree�Address or Fue Number and City o�Well or Bor�ng Locahon , j
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f k)� Depih Belore Sealmg �� � � fl. Original Depih "�"� `� ft.
� �. r a v�in
Show exac�localron of well or bonng Sketch map ol well or bormg Sta�ic Wa�er Level ,�Accurete
�n section gnd wAh�X�� locatwn,showing property hnes.
roatls.and bwldings ❑Approximate
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1 ) � �.
-- --- --- -- �yN yn� k.� �-, �.. r,�'
� � � � '\� '��- �Single Aquder ❑Multiaqwfer fl. below above land su�face
i i i i
_�- -�- -i- ��� CASING TVPE "
W i ; i i T (
_ _r_ _'
i i i ,'_k �Steel ❑Plastic ❑Tile ❑O�her
-- - �- -�- -�- ,� .`.�
_ i
S �� Screen irom to fl. Open Hole irom to R.
�—�'^'k� OBSTRUCTION/DEBRIS/FILL
�Obslruction ❑Debns ❑Fill
PROPERTV OWNER'S NAME
,�;�i � �._ f. , � , ,< � j � �
Type of debns/obsiructwn - � �
MaJing Address d ddferent than property address indicaled above � '
Obsiruchon/Debns/Fill removed? �Yes ❑No
PUMP
:hf ,r.r; ti;
Removed ❑Nol Presen� ❑ Other
CASING
GEOLOGICAL MATERIAL COIOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space mAially giouted7
II not known,ind�cale esfimated formation log irom nearby well or bonng.
�/ ��
� `� in.from lo � '� '� It. ❑Yes �o ❑Yes ❑No �'J.Jnknown
m.irom to fL ❑Ves ❑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 iremie pipe
❑Casing Pertoration/Removal
in.from to fl. ❑Pertorated ❑Removed
m.irom to fl. ❑Pertorated ❑Removed '
Type of pertorator
❑Other
GROUTING MATERIAL
Grouting material�`.'r:�,� � � i C� irom �to ��� ft. yards (l bags
from to N. yaids bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
'� � ! from to fl. yards bags
� l�.le �� - .�
from to ft. yards bags
� !`i �`J���' , f � !�"� UNSEALED WELLS AND BORINGS
Other unsealed well or boring on propeny? ❑Yes �(No
_ a,,. , _ . . LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed m accordance with Mmnesota Rules.Chapter 4725.The mformation contamed in this report is
true�o ihe best of my knowledge.
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! ��- . � ' i� ,.ri- 1
Contractor Busmess Name L�cense or Reg�stra6on No.
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Authonze epresenfafive Signature Date
N � -�' i^.`1 � �)v u ✓. `� r�✓
�Q�.w',[.�L.,�,7.W'v7 •• ` � Name ol Person Sea6ng Well oi Bormg
HE-01434-01