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Minnesota Well and Boring
wELL OR BORiNG LOCATiON MINNESOTA DEPARTMENT OF HEA�TH Sealing No. H
co���Y Name , WELL AND BORING SEALING RECORD Mi��eso�a u��q�e No
Mmneso�a Statutes.Chapter 103/ or W-series No.
���'.,^ ✓�i:�"% �'� ILeave Dlank il nol knownl
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Towns�ip Name To ship No Range No Section No Fraction�sm �Ig� Date Sealed � Approximate Date Well F .
� or Bonng Constructed � `� � r ' �
('?r�c�v► � �,4 �„ �,4 � —/ f' � .� ; �.
Numencal Stree�Address or Fue Number and Cdy of Well or Bormg Localwn �') ^j � � �
,` OC GC
f� �� ,� ��ni�,��� \ {. ! �f � ;7��,.; . ;f� epth Before Seahng ft. Onginal Depih ft.
� 4
Show eKact locatan of well o�bonng Sketch map of well or bonng Stafic Water Level �Accurate
in section gritl wdh��X��. location.showing property 6nes. � .
roads.and byildinqs
❑Approx�mate
N �
��V�:�1 --� �"� — �<.
k, � Single Aquder ❑Multiaquder `f' �`l fl. —� below aboe'e land suAace
�
_�_ - - -- ( � n CASING TVPE
w -- ; ; � � �
-- -,- -r-
i } �Steel ❑Plashc ❑Tlle ❑Other
i i i ,
.mi�e � \
i i_ i i � � e
-I' i ___ __ �..
��"`"re"'--•' �" Screen irom b f1 Open Hole from to ft �
�-- t Sile� , � .
L..._..--------��- OBSTRUCTION/DEBRiS/FILL
S
�Obs�ruc0on ❑Debns ❑FII
PROPERTY OWNER'S NAME �.� '�, �
j� �r i -_i c� �l� � �.�rv�c� r� ��,� (,ir ,: 4: t; ��, � C � � ;::� %�t�yi�..
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Type o�debns/obstruciwn ' '" �—
Ma�6ng Address d ddterenl ihan propeAy address mdicated above.
/ Obstruchon/Debns/Fill removed? � Yes ❑No
/�f t�f" / �V y � Cl SL` E/�� PUMP
��7 Z't`�' ''` ��� ���� � emoved ❑Not Presen� ❑ O�her
�
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO •
FORMATION
Diameter Dep�h Se�in oversrze hole9 Annular space mdially grou�ed?
It not known.indicate esUmaled brmation log Irom nearby well or bonng. ^^}} ,,.�.)
jZ� � � in.from �to(7�L]t. ❑Yes �No ❑Yes ❑No �Unknown
��
m.from �o R. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.irom to ft. ❑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 grou�ed with tremie pipe
❑Casing PeAoration/Removal
in.from to ft. ❑Perforated ❑Removed
m.irom to ft. ❑PeAorated ❑Removed �
� Type ot pertorator
❑Other
�.� GROUTING MATERIAL
t 'T
f t 1. V�i/ �Y r, ..{, t �r^� � ''")
�..
Grouting material t -L���� 4 �ti' ' 11�� from b�✓ to �^' y �ft. yards �bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to R. yards bags
from to it. yards bags
UNSEALED WELLS AND BOHINGS
Other unsealed well or boring on property7 ❑Yes No
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The informat�on contained�n this report is
- true to ihe best of my knowledge.
�� ,� � ( � �. <. � .��� C� ��
� �Contractor Business Name � License or Reg�sfrafion No.
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�!, , �'�. , / _ •' j .
1 t "- J
Aufhirzed Rep�esentahve SignaNre Dafe /
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." %' . .�. ,�_.� . ;��r
����� H �5�3� Name ol Person Sealrng Well oi Bonng
HE-01434-01