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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12 6 51 � <br /> WELL OR BOR�NG LOCATION WELL AND BORING SEALING RECORD Sealing No. <br /> County Name <br /> �E:IIII�-'j')111 Minnesota Statutes.Cha ter 1031 Minnesota Unique No. <br /> P or W-series No. <br /> (Leave blank if not known) <br /> Township Name Townsh�No. Ran�e No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> �re�n� 1 1 � �3 i� r _. <br /> � � � � — �;s.t� 7 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location � � <br /> �1�li y 2��r�.h�ore Dri�e Orcn 9epth Betore Sealing ���a ft. Original Depth ��G ft. <br /> Show exact location of well or boring Sketch map of well or boring A IFER(S) STATIC WATER LEVEL <br /> in section grid wi[h"X'. �':���� location showing properry ��ngle Aquifer ❑ Multiaquifer <br /> �����.,�ines,��buildings. �,,,/ <br /> N �'� W UBORING 1CI�Measured ❑ Estimated <br /> � � Water Supply Well ❑Monit Well � <br /> _ _ _T_ _l__ __ __ �r <br /> \G� <br /> ❑ Env.Bore Hole ❑Other � ft. �elow ❑ aboveland sudace <br /> W —�- -i-- -�-- --i— E CASING TVPE(S) <br /> � � <br /> � <br /> I I I � � ��, � ����� ��.���l �Steel ❑ Plastic ❑Tile ❑ O <br /> -'�- -�-- --;-- --;-- � ,.� - j ther ' <br /> I4 mlle jt-:. •. + <br /> __�' '�__ �_ �__ � �� '_..._...,A.__. 1 CASING <br /> S � Diame�� Depth � Set in oversize hole? Annualar space initially grouted? <br /> �t mi�e—�,�e � in.from U to ��`o R. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> I <br /> PROPERTY OWNER'S NAME in.trom to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> tT1II1 �,:IGciT'�' <br /> Property owner's mailing address if different than well location address indicatetl above. in.from _ to tt. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> r / <br /> Screen from //� to �2C% ft. Open Hole from to tt. <br /> OBSTRUCTIO WDEBRIS/FILL <br /> WELL OWNER'S NAME �Obsiruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> } /� <br /> Well owner's mailing address if diflerent than property owneYs address indicated above. Type of Obstruction/Debns/Fill -..tNNE� �1/� � �r/ <br /> Obstruction/Debris/Fill removed? �Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COIOR HARDNESS OF FROM TO � Removed Ip�Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated fortnation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> p. �No Annular Space Exits <br /> ;..� .'i� .� i%'L� <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforeted ❑ Removed <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> d r�T /� � �/, � <br /> Grouting Matenal N C��?l�on l to� ft. yards � ba s <br /> 9 <br /> from to R. 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 �No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <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 /> i;C1iv :�'�'ODU�� 'f��:I,L DRILLIIti� CU. , IMC. 2 1 17:� <br /> Contractor Business ame License or Registratlon No. <br /> i / <br /> _�./ '�%, � - _� � � y <br /> / <br /> uth z Represenfative$ignature Dafe <br /> \ - . <br /> ,\, . _�,�� .:��.c-✓�....X•+r.Y'-�,� <br /> �'e,. ,.y_ �.. <br /> LOCAL COPY H 12 6 516 Name ol Person�e�ling Well or Bonng <br /> HE-01434-02 10/95R <br />