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'' WEIL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 4 2 9 0 5
�o���Y Name WELL AND BORING SEALING RECORD M���esota u��q�e No , .
�p� Minnesota Statutes.Chapter 103/ or W-series No.
fLeave blank il nol knownl
�-. Township Name Township No. Range No. SecUon No. Fraction(sm. �Ig.� Date Sealed Approximate Date Well
� ��� �� �Q �����/n � � or Boring Consiructed
Numencal Street Address or Fue Number and City of Well or Boring Location �� / /r�� �
67`tV � � Rd RO � I�1 55391 Depth Before Sealing ��-= ft. Original Depth { - fl.
�� Show exact location of well or bonng Sketch map of well or bo�ing Static Water Level ccurate
in sec�ion grid wi�h��X`. location.showing property lines.
N .,
roads.and bwldings. ❑Approximate
� � � � �
'i_ _i_ 'i_ _i_ �
,Single Aquifer ❑Multiaquifer , � ft. � below above land surface
i i i i
_i_ _�_ _i- -i- CASING TYPE
W i i i i E
� i i i
-r -�- -r- -r
i i i i � .\ teel ❑Plastic ❑Tile ❑Other
-mile
_i i i i_ � _�_ '... / /
I I I � y
4. � �,�
� Screen from� to �— fl- Open Hole irom to fL
�—1 mile--� OBSTRUCTION/DEBRIS/FILL
bstruction ❑Debris ❑Fill
PROPE TY OW R'S NAME
Leo�'Satx�y Eollock 471-7252 //�
Type of debris/obsiruction ��tiF r� ����� � ���`- �,rf�i�
Mailing Address d different than property address indicated above.
- Obsiruction/Debris/Fill removed? Yes ❑No
PUMP
.Removed ❑Not Present ❑ Other �'L� �����
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space initially grouted7
� tl not known,mdicate estimated formation log from nearby well or bonng. �
drift �in.from �to � ft ❑Yes �YJo ❑Yes ❑No ❑Unknown
in.from to ft. ❑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 AND BORE HOLE:
o Annular Space Exists
❑Annular space grouted with iremie pipe
❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of perforator
❑Other
GROUTING MATERIAL
/
� '�}
Grouting material tiL/�%CEN�,/4�rom �to ��ft. yards �{bags
from to ft yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to tt yards bags
�� 9" w�elt I32' ��P (rom to ft. yards bags
� ZZ �S �t UNSEALED WELLS AND BORINGS .
1'* 1FJri UCllt�� Other unsealed well or boring on property? ❑Yes
` 2 I�IEn �r� �g � C�� �'C�,�L � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION �
� This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The informa6on contained in ihis report is
true to the best of my knowledge.
DOl1 $�Ol�O2.A �I.Z I}r�1�.�Tig e0.! �T1C. �7172
Contractor Business Name License or Registration No.
I�. ���� �����5�` 9-3C�-93
h ed epresentative S�gnature Date
H 429 0 5 J� �'`°�°n
LOCAi-C;C�Y
Name ol Person Sealing Well oi Boring
H601434-01