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Minnesota Well and Boring <br /> WEIL OR BORiNG LOCA7iON MINNESOTA DEPARTMENT OF HEALTH Sealing No. H C <br /> WELL AND BORING SEALING RECORD^^���esota u��q�e No <br /> County Name Or W-SefieS NO. <br /> Il(:11I'lE:��3.t: Mmnesota Statutes.Chapter 7031 ��ea�e eia�k�i�oi k�ow�i <br /> Township Name Townsh�p No Range No Seclion No Fraction(sm �Ig� Date Sealed Approximate Dale Well <br /> or Bonng Consiructed <br /> i�rcr.�: !17 ��? i;is '?�_;ct,�t��'�a Z �''j <br /> Numencal Street Address or Fue Number and Cay ol Well or Bonng Location � f <br /> ���S1' 1���i�[: ��.�i: �-:V�-'. i�� ':�.i� 1".il'l. i ' ��f?f! Dep�h Before Sealing /�� fl. Onginal Depih �� ft. <br /> Show exact locatwn ol well or bonng Sketch map of well or bormg Static Water Level ccurete <br /> m section gnd with��X location.showmg property hnes. <br /> roads.and bwldings ❑Approxima�e <br /> N <br /> _ � . . �,t �,1 <br /> _�_ <br /> ingle Aquder ❑Muhiaquder � fl. � below aboe�e land suAace <br /> i <br /> W �_ _�_ -�- -i- CASING TVPE <br /> i i i � i _i'• <br /> �� . <br /> i i i i _ -. <br /> -r -�- -r- -r <br /> i i � i � ! Steel ❑Plastic ❑Tde ❑Other <br /> •m��e <br /> __ _ �_ 'i _ __ � ....-..._�.�.._�.�.._..__� / <br /> _ ' / <br /> Screen from� to � it. Open Hole from to ft <br /> S <br /> r-- im�ie-� OBSTHUCTION/DEBRIS/FILL <br /> Obsiruction ❑Debns ❑Fill <br /> PROPERTY OWNER'S NAME <br /> f`►c::L C �3L�r;1:'� <br /> / wI! � <br /> Type ol debris/obstruction �L_1�L/YS� "�� � �f/ <br /> Maihnq Address il ddlerenl than prope�y address indicated above. <br /> Obstruction/Debris/Fdl removed? Yes ❑No <br /> PUMP <br /> �Aemoved ❑Not Present ❑ Other ��f / ��� <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO • <br /> FORMATION <br /> Diameter Depih Set in oversrze hole7 Annular sp2ce initially grouted� <br /> If not known.indicate esOmated brmahon log irom nearby well or boring. � <br /> �// /��� <br /> _ in.from � to �Ln� f�. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> :.� r `1 ' <br /> i�� <br /> m.irom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BOHE HOLE: <br /> No Annular Space Exisls <br /> ❑Annular space grouted with�remie pipe <br /> ❑Casing Perfora6on/Removal <br /> in.irom to ft. ❑Perforated ❑Removed <br /> in.from lo fl. ❑Perforated ❑Removed <br /> Type ol peAoralor <br /> ❑Other <br /> GROUTING MATERIAL <br /> r�+ ../...-� ,.� <br /> t <br /> Grouting material/���C_.�'���/'�+jlrom �_to ,�Q�ft. yards �bags <br /> from to ft yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft yards bags <br /> from to ft yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes o <br /> LICENSED OR REGISTERED CONTRACTOH CEHTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contamed in this report is <br /> - irue to the best of my knowledge. <br /> 1,7(_%� :��{.��.'a�:l�', �Y�'.�.-�. �.�Y�.1��..f� �.;;:'.� 1.1`tl.. ::�� /.:: <br /> Contractor Business N e ' �' i, License or Reg�stra6on No. <br /> J �- <br /> ^'"",�-.' � 'Y/�Y� �' <br /> orucsdRepresenfatrve Signafure' Dafe <br /> .-� F.�� <br /> i _ <br /> ������ n 7�7�9 Name o!Person Sea6ng Well or Bonng <br /> � HE-01434-01 <br />