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s <br /> wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 6 7 3 5 � <br /> WELL AND BORING SEALING RECORD M nnlesoNa Unique No. ` <br /> County Name " <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank it not known) <br /> Towns ip a e Township No. Range No. Sedion No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> % '/< � � <br /> Numerical Street Address or Fire Number and City of Well or Boring Location � � <br /> Depth Before Sealing �Q`� ft. Original Depth �V1�! ft. <br /> Show exact location of well or boring Sketch map of well boring A� IFER(S) STATIC WATER LEVEL <br /> in section grid with"X". �ocation, showing roperty ingle Aquifer ❑ Multiaquifer <br /> l lines,roads,and bui in� <br /> N ���' � WELUBORING �uleasured ❑ Estimated <br /> � � <br /> ater Supply Well ❑Monit.Well <br /> _T_ _T_ __,__ __l__ � � � <br /> `�v �Env.Bore Hole ❑Other _�_ft. [�elow ❑above land surface <br /> � � � � _..` <br /> --�- -�-- --i-- --i-- J') <br /> W E ,_....._'4 � CASING TVPE(S) <br /> � i � � <br /> I � <br /> i i i i .� <br /> —�- -i-- -�-- --�- �� �Steel ❑ Plastic ❑Tile ❑Other <br /> Y.mile ---- � <br /> -�-- -�-- -�-- --�-- � . —... �'.Y CASING <br /> .__......___ �. Diameter Depth Set in oversize hole? Annualar,pace initially grouted? <br /> l� """��J""" J <br /> �r mile—�e � � in.from� to�� ft ❑ Yes `C7No ❑Yes ❑No ❑ Unknown <br /> � )r.t <br /> PROPERTY OWNER'S NAME . _ in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> Property ner's mailing address if diHerent ihan well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ UnknoWn <br /> SCREEN/OPEN HOLE <br /> 1 � <br /> Screen from��to�p_ ft. Open Hole from to ft. <br /> OBSTRUCTIO WDEBRIS/FILL <br /> WELL OWNER'S NAME glObstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> /� � ,, � /� /� <br /> Well owner's mailing address if diHerent than property owner's address indicated above. Type of Obstruction/Debris/Fill T„�,/��,�����`"'T Q. T_�'j�/� <br /> Obstruction/Debris/Fill removed? es ❑ No <br /> PUMP <br /> Type f✓1/a Iv/lm/" <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO emoved ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby weli or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> . �No Annular Space Exits <br /> �� '� � Annular space grouted with tremie pipe <br /> i'.� ❑ 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 /> ;+� t <br /> Grouting Material ���d+��/9'�LEqrtl �_ to��ft. yards � 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 o <br /> LICENSED OR REGISTERED CONTRACTOR CERTIF ATION <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 /> Dan stc��1� �aAt� �-i�� �-� r,�..Tlr�c. •27172 <br /> Contractor Business Name f License or Reg tration No. <br /> �---'�� , <br /> / r', <br /> e �"n e Signatur Date <br /> ----�-;` Ar° -_.�._.• �Z4... <br /> i._. <br /> LOCALCOPY H °� n � 7 � � Nameo�alingWel/oreodng <br /> �✓ � <br /> HE-01434-02 10/95R <br />