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Minnesota Well and Boring <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 5� �8 8 <br /> CouMy Name ` WELL AND BORING SEALING RECORD M��nesota���q�e No. <br /> ) Minnesota Statutes.Chapter 103/ or W-series No. <br /> / t°'h L1, ILeave blank if nol known� <br /> Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br /> , � ° _ -j�� or Bonng Constructed _.� - ' <br /> i i t <br /> ll r "..�t/ir: ra r.a ia : � ?�. . . <br /> Numerical Sireet Address or Fire Number and Gty o(Well or Boring Location . { _� � <br /> �1`� r � �` r � /' <br /> f ,(''/J � � `, � '�.r , v'' ':� . Depth Belore Sealing ft. Original Depth ft. <br /> A.� �- <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level �.Accurate <br /> in section grid with�'X`. location.showing property lines, ' <br /> N roads.and buildings. ❑Approximate <br /> i i i i <br /> -- -i- -i- -� �'�.... <br /> ! -��'j �'Single Aquifer ❑Multiaquifer ft. � below above land surtace <br /> i i i i � , 1 <br /> _i_ _�_ _i_ _i_ CASING TYPE <br /> W � � � � E �l <br /> � � � � T <br /> _�_ _�_ _r_ _r T !<J(` . _ <br /> � i i � � 4 � �.Steel ❑Plastic ❑Tile <br /> '%mile ❑Olher <br /> i i i i <br /> _i_ 'i_ _i_ '- . !'i+ � .'""_-�� <br /> ��,: "! `� <br /> S � ' - Screen from to ft Open Hole irom to ft. <br /> r-1 mile-►{ ` \���``+„ OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME �Obstruction ❑Debris ❑Fill <br /> .�- <br /> r i' „ ! � �` j ` : ? ` <br /> Type of debris/obstruction _ <br /> Mading Address rf ddferent ihan property address indicated above. <br /> Obsiruction/Debris/Fill removed? �Yes ❑No <br />' PUMP <br /> . '....�.<,�,... <br /> � Removed ❑Not PreseN ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space ini�ially grouted7 <br /> If not known,indicate estimated formation log from nearby well or boring. ; , <br /> � � <br /> ��J�/ �`y'' in.from � ' to �'� ft. ❑Yes +�f�lo ❑Yes ❑No �Unknown <br /> in.trom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to fi. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �,,.No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to tt. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> � ) � <br /> � / f = ba s <br /> Grouting material Z - from to � ft. yards g <br /> from to ft. yards bags <br /> . REMARKS,SOURCE OF DATA,DIFFICULT�ES IN SEALING <br /> ��� � �� from to ft. yards bags <br /> . , r <br /> from to ft. yards bags <br /> 1 (. . t _ UNSEALED WELLS ANO BORINGS , ,�,-�, �� ,� <br /> I i <br /> 9 . + 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 r--� <br /> C. <br /> Contractor Business Name License or Registration No. <br /> � ��__. � �_ �j' G , <br /> ! <br /> Authorized Representative Signature Date <br /> 58088 �', � „ { - ��t <br /> LOCAi.COF'Y H .�. ' � . <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-01 <br />