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Minnesota Well and Boring <br /> WELL OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 3 6 5 6 4 <br /> �o���Y Name WELL AND BORING SEALING RECORD M���esota���q�e No. <br /> Minnesota Statutes.Chapter 703/ or W-series No. <br /> .�L>�j, ,,,A ��c.,ve biank J not k�owm <br /> Township Name Township No. Fange No. Section No. Frachon(sm. �Ig.) Date Sealed Approxima�e Date Well <br /> � \ or Boring Cons�ruc�ed <br /> +j y ' y, �ia �la '�a f ""' d. -�-. �i _' , �, <br /> Numencal S�ree�Address or Fire Number and Cdy of Well or Boring Location <br /> G T �� '�t � Dep�h Before Sealing � ��� ft Original Depth —��� ft <br /> s <br /> Show exact Ixation of well or boring � ' Sketch map of weli or boring Static Water Level �Accurate <br /> in section grid with-X-. location,showing property lines. <br /> roads,and buildings. ❑Approxima�e <br /> N <br /> � � � i_ 1' <br /> __ ___ _-_ ' �\ <br /> {� �� �$ingle Aquifer ❑Multiaquifer ��—fl. —�.- below above land surface <br /> i i i i <br /> _i_ _�_ _i_ _i_ ` CASING TYPE <br /> W i i i i E �. Y'';'.,_ t���'�': �,,,e' <br /> i i i i <br /> i i i i � 1` �y teel ❑Plastic ❑Tile ❑Other <br /> o mile 7 <br /> i i i i t <br /> __ _ i_ _i _ _i � '� �. <br /> S t Screen from �o ft. Open Hole from to ft. <br /> �--1 mile--►I , d�'�Y � �� OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME �J*^ �Obstrudion ❑Debris ❑Fill <br /> .r.. ] 1/{� . � :. j w� <br /> �� �� �� Type of debris/obstruction l--J -[ � ���'t` � f' ` �� 1 " <br /> Mailing Address rf different ihan property address indicated above. T� ! <br /> Obstruction/Debris/Fill removed? es ❑No <br /> PUMP <br /> �`- rl'�--�: <br /> "' [},�Removed ❑Not Present ❑ Other <br /> i <br /> CASING <br /> RDNE O€ <br /> GEOLOGICAL MATERIAL COLOR ,'��qRMA�pN P Mh O <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? - <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> �� . � in.from _�_to �1_� ft. ❑Yes �(No ❑Yes ❑No �Unknown <br /> % `�` <br /> in.from to fl ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from [o ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �o Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> m.from to fl. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of peAorator <br /> ❑Other <br /> GROUTING MATERIAL <br /> t (j! ,i <br /> Grouting ma�erial !�_ from �_I to _J ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> � i t f <br /> .... �,f� 4{ `� � � � y � from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> � t/��"� t ��� � f� r��~' � Other unsealed weli or boring on property? ❑Yes �IQo <br /> t <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> Thls well or bonng was sealed m accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> irue to the best of my knowledge. <br /> �''' � /t � {, � 7 � �`�a <br /> Contractor Business Name : License or Registration No. <br /> ` ', � <br /> t ;t,.�..� ( jf:�%w'"� `_�° "" '� - <br /> Authorized Representiat�ve S�gnature �i Date <br /> / <br /> '� ; j ; �.,'� . t � <br /> LOCAL COFY '„I ' � �` �-.:%' ., ,, i <br /> Name o/Person Sealing Well or Boring <br /> HE-01434-01 <br />