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