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WELL OR BORING IOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
County Name WELL AND BORING SEALING RECORD Mi��esoca u��q�e rvo.
����� Minnesofa Statutes.Chapter 1031 or W-senes No.
ILeave�lanx il nol known�
Township Name Township No Ranqe No SecUon No Fraction(sm �Ig.) Date Sealed Approximate Date Well
or Boring Conslructed
�«� I17 zs o� a�—cx�2e.a F
Numencal S�reet Address or Fue Number and City ol Well or Bonng Locatwn �y���---yyy / / ��; /
99/.�1 .t,7 Ci.�re T... �O� Depth Bebre Sealing ��r.I C�� ft. Onginal Depih J ...�— fl.
.JJ�fG 'Y 7IN /✓1
Show exacl�cealion of well or bonng Sketch map of well or bonng Static Water Level Accurate
m sec�wn gnd with��X��. locatwn.showing propeAy hnes. �
. . �"���""�'"' roads.and bwldmgs ❑Approwmate
N ( �
� � �- � � � ' i
-- -- -r- -,s
� � , _.._._..,
Single AQuder ❑MulGaqwfer �ft. � below above land surtace
;
-�- -�- -`- -'- :..---�--_� ,----_.._.__�. ._ CASINGTVPE
W ' ' E } �
� � � � �
- -,- -�- -�-
i � i �� � ,_,____�_�_______ �Steel ❑Plashc ❑Tile ❑Other
_i_ _�_ ___ __ �y r , . , . , / � r
� ( ��/
i Screen from�-a.1--�— Io �� fl. Open Hole from lo ft
�'—�S'k� .%� , , .t"-f j'�'� OBSTRUCTION/DEBRIS/FILL
ObsVuction ❑Debns ❑Fill
PROPERTY OWNER'S NAME
ype ol debris/obstructwn..,� �JA�`� ���� � ����
Mai6ng Address d ddf rent t an propeAy address indicated above.
Obsiruction/Debns/Fill removed? es ❑No
140Q0 Veit Place PUMP
Rogers, P�+I 55374 2 of Z ,5,�� r�U�lo
Removed ❑Not Present ❑ Other�
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Dep�h Set in oversrze hole? Annular space inAially grouted�
If not known.indica�e estimated formation log from nearby well or bonng. � /
/ /� �
�"�.in.from �,,.L to fl. ❑Yes �No ❑Yes ❑No ❑Unknown
f
'� ���1 in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown
l
in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAH SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
o Annular Space Exists
Annular space grouted with�remie pipe
❑Casmg Perforation/Removal
in.from to fl. ❑Perforated ❑Removed
in.from to n. ❑Perforated ❑Removed
Type of perforator
❑O�her
GROUTING MATERIAL
Grouting matenal�ll/�Ap C.��� �to �ft/ yards / f bags
from to ft. yards bags
REMAHKS,SOURCE OF DATA,DIFFICULTIES IN SEALING �
F
hom to fl. yards bags
irom to ft. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property7 ❑Ves �No
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minneso�a Rules,Chapter 4725.The informadon coMained in ihis repon is
true to ihe best of my knowledge.
Don Sta.io2at�ell Dr3.l.lir� Co., Inc. 271?2
Conhactor Busrness� �; License or Registia6on No.
�
/���� ��- �_��' f• �l �:
on d RAp`ieserN3�ve SignafLre � Dafe
.__.__..r ----"`..�..
--`�- . _ •' . .� . ., .._._.. „ \,�-
H _.._ _ �-.,_
�.
�„�,���' � Name o!Person Seahng Well or Bonng
. HE-Ota3a-01
�. _
Minnesota Well and Boring
wELL OR BORiNG LOCarION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
County Name WELL AND BORING SEALING RECORD^^���eso�a u��q�e No.
T���� Mmnesota Stafutes.Chap�er 103/ or W-senes No.
ILeave blank iI not knownl
Townsh�p Name Townsh�p No Range No. Section No Fraclion(sm �Ig) Dale Sealed Approwmate Date Well
�� ��� 23 � ����'a � -� �/- or Boring Conslruc�ed
�'S
Numencal Slreet Address or F�re Number and City of Well or Bonng Lowt�on � / f
3�2 t� � � �� Depih Before Sealing ��� ft Ongmal Depth � ft
SFww exact locat�on of well or bonng Skelch map of well or bonng Static Water Level Accurale
in sechon gnd wdh��X��. IocaOon.showing property lines.
, �-�� - � roads.and buddmgs. ❑Approximate �
� � � 1 i _ , i ��+ f
-- ---N-- -- , , i _ .._... �.
� � � �� � $ ' Sin le A ui�er �'�'
g q ❑MulUaqurfer fl. below above land suAace
i i•
i i ;
_..
_i_ _a_ _i_ -- CASING TYPE
W � � � 1 E
- -�-
i i �k � � _ ,�� Steel ❑Plashc ❑Tile ❑Other
� �- - �- --- -- - / /
-�
S I I � � Screen from /�� �o � f� Open Hole Irom to ft.
�--1 mile—� �.' - OBSTRUCTION/DEBRIS/FILL
Obs�ruction ❑Debris ❑Fill
PROPERTV OWNER'S NAME
d'eit Cam 428--2242 ,.,��i�...�� l�-''j�� � /�Ul7�/�
Type of debris/obsirucUon
� Mailing Address d ddterent than propeAy address indicated above. €
1`i� v�j C nZ$� 1 O� � Obstrudion/Debns/Fill removed� es ❑No
ROgCls, MN r55374 " PUMP
Removed ❑Not Present ❑ Other �`"u" • "" ��
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO .
FORMATION
Diameter Depth Set in oversize hole9 Annular space initially grouted�
If not known,ind�cate estimated lormation log irom nearby well or bonng. ,� / /
� in.from S�lo � ft. ❑Yes �lo ❑Yes ❑No ❑Unknown
in.from to n. ❑Ves ❑No ❑Yes ❑No ❑Unknown
in.�rom to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
.o Annular Space Exists .
❑Annular space grouted with tremie pipe
❑Casmg Perforation/Removal =
m.irom to ft. ❑Perforated ❑Removed
in.irom to fl. ❑Perforated ❑Removed
Type of perforator ��
❑Other
GROUTING MATERIAL
/ /�,>ly� /. /
Grouting material /V�� ��`_'�/'�.�Y(6m G./ to �ft. yards �bags
from to ft yards bags
� REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to fl. yards bags
from to fl. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑Yes o
� LICENSED OR REGISTERED CONTHACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The intormation contained in this report is
� �rue to the best of my knowledge.
� sc«�oi$ �i� cx��l� co� T�. 27272
� Conhactor Busrness Na7ie ' �` �� /'��� License or Registrabon No.
.�-�'', � / . �( � �
Ji�'//.�✓ ��i��i����'_�
GidlTo d Representative S�gna— ture� Date
_.�- ��� _
{.� .. - . .,� . ,...__. � ..
u�����' ■■ Name ol Person Sealmg Well or Bonng
HE-01434-01