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� . <br /> WELL OR BORING LOCA71oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 110 716 <br /> WELL AND BORING SEALING RECORD Sealing No. <br /> Counry�ame Minnesota Unique No. <br /> � - Minnesota Statutes,Chapter 1031 or W-series No. <br /> � ��- !� (Leave blank if not known) <br /> To ship Name To ip No. Range No. Section No. F�ction.(sm.-s Ig.) Date Sealed Date Well or Boring Constructed <br /> j4; � l:� � - .�!..i �--'i�'i `-�� � <br /> ; <br /> �rTumeYcal t eet Addres's or Fi e umber and City ot Well or Borin Location j l ,7 <br /> � ` <br /> ;,� � Depth Before Sealing / � ft. Original Depth tt. <br /> I <br /> Show exa�ct-'locati� of well or boring � ch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property g Single Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. <br /> N WELUBORING �Measured ❑ Estimated <br /> � �Water Supply Well ❑Monit.Well �„� <br /> - - - - -- -- --i-- �{ <br /> ❑ Env.Bore Hole ❑Other r � tt. ❑below ❑above land surface <br /> W --�- -�-- -�-- --i-- E CASING TYPE(S) <br /> � � <br /> � � <br /> � � � i <br /> --�- -�-- --�-- --�-- [�Steel ❑ Plastic ❑Tile ❑Other <br /> '/.mile <br /> ' ' ' '_ CASING <br /> --- -'-- --�- --1- � <br /> ' ' ' ' � Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> S G' � Yes No Unknown <br /> �—t mi�e—� _� in.from � to fl. ❑ Yes ❑No ❑ ❑ ❑ <br /> PROP,€R'GY OWNER'SNAME in.from to ft. ❑ Yes ❑No ❑Yes ❑ No ❑ Unknown <br /> '�. ���r. ���:..::� : � ;'� . Yes No Unknown F <br /> Property owner's"mai ing address if di, nt than well Ibcation address indicated above. in.from to ft. ❑ Yes ❑No ❑ ❑ ❑ <br /> SCREEN/OPEN HOLE <br /> Screen from � to�_ ft. Open Hole from to ft. <br /> O B STR U CT I O N/D E B R I S/F I L L <br /> WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if diHerent than property owner's address indicated above. Type of Obstruction/Debris/Fill <br /> Obstruction/Debris/Fill removed? ❑ Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log irom nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ,� No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed � <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> y.� 7 <br /> Grouting Material " 1��J*- � ��ry�4•from f to �' ft. yards bags <br /> �- . - <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES INSEALING UNSEALED WELLS AND BORINGS <br /> %j <br /> �-`� � ? - Other unsealed well or boring on property? ❑ Yes � No <br /> � �''f'✓� -Y � � � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> �f- r �.,�;8=-_ <br /> . This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> �� � '� <br /> ; j <br /> �'`�,� x f %�7�f,�/s.r;�,� ' : , <br /> Cont2ctocBG s anle � ���- �.� l L�cense orRegrstfahon No. <br /> � l %�r' � /N2..�.... 'f !/�r f 6 <br /> � � f / ! <br /> Auth�p�e�n�(b�Signa nI�' ,- �� !' � D�te � <br /> _� � <br /> k <br /> ♦ J " F <br /> / 1 /1 7.� _�I^;��f7, ..^�.f! ! <br /> � Narp�o%4�ersOtf,Sa�lintf t�kll or8bring "-` <br /> LOCAL COPY H � � � ! � � <br /> HE-01434-02 10/95R <br />