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. <br /> _ �.- _ . _ <br /> Minnesota Well and Boring <br /> � WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 4 4 8 7 � <br /> � co���Y N,me WELL AND BORING SEALING RECORD Mi�nesota uniq�e No. <br /> Minnesota Statutes.Chapter 1031 or W-series No. <br /> i.n �Leave blank�I not known) <br /> 1 <br /> Township Name Township No. Range No. Section No. Fraction(sm. �ly.) Date Sealed Approximate Date Well <br /> � � � ,,.ti or Boring Constructed <br /> / �ra � <br /> Numencal Sireet Address or Fire Number and City ot Weil or Boring Location � � <br /> Depih Before Sealing ��� fl. Original Depth ��� ft. <br /> Show exact location of well or bonng Sketch map of well or boring Static Water Level ccurate <br /> in sec�ion grid wi�h��X��. bca io�,s�i�ng property lines. <br /> a roads,and buildings. ❑Approximate <br /> N � � <br /> � � � � <br /> __ ___ '__ _i ���y <br /> ingle Aqurfer ❑Multiaquifer ` "� —fl. --�a-- below above land surface <br /> i i i i <br /> _i_ _�_ _i_ _i_ CASING TYPE <br /> W i i i i E <br /> i � � i <br /> - -r -7- -r- -r <br /> i i i i teel ❑Plastic ❑Tile ❑Other <br /> mi�e <br /> _i i i i �� ♦�,r <br /> � <br /> I- - I- _I - � Screen from to fl. Open Hole(rom �""'�-�` to Z Z� fl. <br /> ��S��e� --Y`•;t-�� ....F!_� 'f �.�'{ OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME �Obstruction ❑Debris ❑Fill <br /> 1�1 GTeig �t73"777fi Qs-f Q <br /> Type of debris/obsiruction ��A✓F� r L.!�� T� ��� <br /> Mailing Address if ditferent ihan property address indicated above. <br /> Obstruction/Debris/Fill removed? �Yes ❑No <br /> PUMP <br /> Removed ❑Not Present ❑ Other v�� / �%�r1� <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �' <br /> FORMATION <br /> Diameter Depih Set in oversize hole? Annular space initially grou�ed? <br /> I(not known.indicate estimated formation log from nearby well or boring. <br /> �! I �yr/ t <br /> in.from �to �ft. ❑Yes �Plo ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> � '� <br /> s_ , -� <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> L]�tilo Annular Space Exists <br /> f � <br /> ❑Annular space grouted with iremie pipe <br /> ❑Casing Perforation/Removal <br /> m.from to fl. ❑Per(orated ❑Removed <br /> m.from to ft. ❑Perfora�ed ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> ! <br /> � f <br /> Groutingmaterial /�-�E�� �����om ��to �ft. yards �r bags <br /> y. <br /> from to ft. yards bags <br /> �" REMARKS,SOURCE OF DATA,DIPFICULTIES IN SEALING <br /> from to ft. yards bags <br /> ap� from to ft yards bags � <br /> ���`t �~ j��� �' �'��Y UNSEALED WELLS AND BORINGS p <br /> 1� t18g9 C�Iit <br /> 1��� ���� Other unsealed well or borfng on property� ❑Yes o <br /> 41ilGIZ 1$Wr� rig & c�t �ront �np LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to ihe best of my knowledge. <br /> Don stcxt�l� ��l l t�i l lir�_�'� Inr 27172 <br /> Conhactor Business Name �T L�ense or Registration No. <br /> ' ��,-�'l , <br /> ,��.�'_f�. <br /> Authorized Represenlafive Signature ate <br /> LOCAL COPY H �4,8 7 8 `1�I!! ATIt'Oi28011 ' <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-01 <br />