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WELL OR BORING LOCanON MINNESOTA DEPARTMENT OF HEALTH Sealing No
County Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No.
� Minnesota Statutes.Chapter 1031 or W-series No.
ILeave blank if not knownl
Township Name Township No. Range No. Section No. Fraction(sm. •Ig.) Date Sealed Approximate Date Well
/�.�,�,�� q' r� , or Boring Cons�ructed
l.11UaAJ 11� 4J � ` � � . '` .
��a t_-v��.,,� � � c�
Numerical Sireet Address or Fire Number and City of Well or Boring Location
1•1LQ 7..1_,,,..,t� �� /\,,,r.� 1�R.7 Depih Before Seahng �� ft. Original Depth `� r ft.
a.O�3� �J6lC1�YJ. u3.UllV rll7
Show exact location of well or boring Sketch map of well or bonng Sta�ic Water Level Accura�e
in sec�ion grid wdh��X��. bcation.showing property lines.
N � , roads.��ryd buildings. ❑Approximate
� � � �
� � � ••,3 /!'J 'S�_
-,- -,- -r- -;
`ti Single Aquifer ❑Multiaqui(er —�.e.;a�fl. � below above land surface
� � � � �y.
_i_ _�_ _i_ _i- CASING TYPE
W i i i i E �
� i i i � �
-r -�- -r- -r
� � � � Steel ❑Plastic ❑Tile ❑Other
'i.mile
_� � I I_ � �
I I I 1 ''� �
Screen from� to ��-'-1 ft Open Hole from to ft.
S
�—1 mile—►I OBSTRUCTION/DEBRIS/FILI
PROPERTY OWNER'S NAME � Obstruction ❑Debris ❑Fill
Bn�ce Fei.k 473--3T59 —
r _� ;,
Type of debris/obstruction � � ���� C'�
Mailing Address if different than property address indicated above. �
Obstruction/Debris/Fill removed? �Yes Y 0 No
PUMP
❑Removed Not Present ❑ Other
CASING
GEOLOGICAL MATEHIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space initially grouted?
If not known,indicate estimated formation log from nearby well or boring.
t � �
�rt O p.� in.from to �� ft. ❑Yes �No ❑Yes ❑No ❑Unknown
.a �.�
in.irom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
y�rvo Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of perforator
❑Other
GROUTING MATERIAL
/ �
Grouting material��'�',:�� '" � � '�t from `� ' to ��� � ft. yards �bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
�t� �� ��� ��! �� from to ft. yards bags
� ���^ C�,�,,.�j UNSEALED WELLS AND BORINGS
6 IG73 ��W Lit� Other unseated well or boring on property? ❑Yes No
2 1T� 1$Wr� rig & C�C ,��C �� LICENSED OR REGISTERED CONTRACTOR CERTIFICAT�ON
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is
_ true to the best of my knowledge.
Do� Stodal.a Wei2 Drill.ing Co., Itdc. 27172
Contractor Business Name License or Registration No.
a
"�';' ",/'���- 8-27-93
on epresentaGve§ignaNre ° Date
LL%i.H�COP'Y I„I � T�lil I�[!�C£
Name ol Person Sealing Well oi Boring
HE-01434-01