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Minnesota Well and Bonng � � �
WEIL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEA�TH Sealmg No. H
�o��,YName WELL AND BORING SEALING RECORD M���eso�a u��q�e No
j� Mmnesota Sta�utes.Chapter 103/ or W-series No
{�y �� 1Leave blank il nol knownl
7
Township Name Township No Range No. Section No Fraction(sm. �Ig� Date Sealed Approximate Date Well
)- or Boring Consiructed /c7' .,_� �
� �14 �la �ra �~ /�- ` : 1 . ..
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Numencal Sireet Address or Fve Number and City of Well or Bonng�ocation J � � �
� !�) - � DepthBeforeSeahng —.l �� � it. OngmalDepth �-•-� � it.
� .��,� � �l 5 � > )✓:>✓i U
Show ecact IocaOon ol well or bonng Ske ch map of well oi bonng Sla�ic Water Level QAccurete
m section gnd w�th��X�� location.showing property lines.
��.. roads.and bwldings ❑Approzimate
N
-�- - �- --- -;- ;' ___ _ j 7 x
' ' - �t,��� �'� (�,Single Aquifer ❑Mulliaqwter fl. below aboe'e land surface
i � i � f
_�_ _ - -- `1L i CASING TYPE
W 1 I E � .�.,-�—' ..--
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' _�' _r_ _�_
; � � � �� �� � j � � I�Steei ❑Piasuc ❑7de ❑Otner
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-- --- -, - -,
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Screen from to fl. Open Hole Irom to ft.
S
���^�k� OBSTRUCTION/DEBRIS/FILL
�-.Obs�rucl�on ❑Debns ❑Fill
PROPEHTV OWNEH'S NAME
� � � t J � f ` (� �
�'7 <: f �_� TYPe of debns/obs�ruclion •/,t ' ���Y:�i' }�, �(—�. .� - ��-�.
Mailing Address il drtferent Ihan propeAy address ind�caled above
Obsiruction/Debris/Fill removed� ���es ❑No
PUMP
"r �-�.
❑Removed �Not Presenl ❑ Other
CASING
GEOLOGICAI MATERIAL COLOF HARDNESS OF FROM TO •
FORMATION
Diame�er Depth Se�in oversrze hole? Annular space irntially grouted�
If not known,indicate esUmated lormation log irom nearby well or bonng.
� �
� /� �_in.from i-' to } -�� � ft. ❑Yes �No ❑Yes ❑No /�Unknown
�:' /
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
m.from to ft. ❑Yes ❑No ❑Ves ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� �o Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to fl. ❑Perforated ❑Removed
m.irom to fl. ❑Pertorated ❑Removed
Type of perforator
❑Other
GROUTING MATERIAL
� �� �'
�
Grouting material t�. �-^ " from � ' to J � ' ft. yards ��� � bags
from �o ft. yards bags
REMARKS,SOUHCE OF DATA,DIFFICULTIES IN SEALING
irom to fl yards bags
�.,j . �'i S. _ ,
�� from to it. yards bags
� UNSEALED WELLS AND BORINGS �.�1���'� S! � � !
� / i1 ,
! �� � .� i - Other unsealed well or boring on property? �Yes ❑No . �r '�-���.
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed m accordance with Minnesota Rules,Chapter 4725.The mformatron contamed in this report is
� true to ihe best of my knowledge.
! ;. �` � j �jy
Contractor Bus�ness Name License oi Registrafron No
�� f' t :.i.f � ;� ..
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Aulhonzed Represe/rtafive Signature Da�e
� � .. � , . � ��
������,��7�� � ���,�^�� Name ol Person Sealing Well or Borrng
HE�Ot434-Ot