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wELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 2 8 6 5 <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennleso aOUnique No. <br /> � r1 Minnesota Statutes,Chapter 1031 or W-series No. <br /> "*( �;yr. (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> f�y '/a '/a '/a J . �- , /�-. . . . <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> ��:^.-. �? � � ' „ j j ' ; Depth Before Sealing J� ft. Original Depth �,f ft. <br /> Show exact location ot well or boring � Sketch map of well or boring ppUIFER(S) STATIC WATER LEVEL . , _� <br /> in section grid with"X". location, showing property �Single Aquifer ❑ Multiaquiter <br /> lines,roads,and buildings. <br /> N WELL/BORING �(.Measured ❑ Estimated <br /> � _ ., � �. +� -.._ [�Water Supply Well ❑Monit.Well <br /> _T_ _ � " f �� f. <br /> "`�'�-----•------^-• ❑ Env.Bore Hole ❑Other �ft. <br /> ,�below ❑ above land surface <br /> i� <br /> W -r- -i-- -i-- --i- E �,.i` � CASINGTYPE(S) <br /> � i � y <br /> � � <br /> � i i � J� <br /> � � f'- [�cSteel ❑ Plastic ❑Tile ❑Other <br /> -�— -�-- --�-- --�— ,� <br /> � � � � /mile . I.,___r <br /> —�- -�-- —�-- --1-- � ! ( CASING <br /> ���������� Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> q�i mile—�e �_� in.from�_ to�L_ ft. ❑Yes [�No ❑Yes ❑No �Unknown <br /> I i <br /> PROPERTY OWNER'S NAME _ in.from to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> . . — <br /> Property owner's mailin address if different than,well location�address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> r `-. . Screen from to ft. Open Hole from to ft. <br /> O B ST R U C T I O N/D E B R I S/F I L L <br /> WELL OWNER'S NAME [�r Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> i <br /> �,.,y =' �..,_.L.. J <br /> Well owner's mailing address if diNerent than properry owner's address indicated above. Type of Obstruction/Debris/Fill � �!`� � �, � �' 'f <br /> Obstruction/Debris/Fill removed? Yes ❑ No <br /> PUMP <br /> Type �. ,. � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed �� Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated(ormation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exits <br /> �V a <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material j from � to� tt. yards �`�F bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes ' No <br /> , � LICESJSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> 4 ��, , , , <br /> , �' This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> i � <br /> Contracror BusinE§s Name' License or Registration No. <br /> r <br /> Authonzed Representative Signature ` Date <br /> Name ol Person Sealing- e!I or Bonng - <br /> LOCAL COPY H �; � � � �j � <br /> HE-01434-02 <br /> 10/95R <br />