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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 5� �8 8
CouMy Name ` WELL AND BORING SEALING RECORD M��nesota���q�e No.
) Minnesota Statutes.Chapter 103/ or W-series No.
/ t°'h L1, ILeave blank if nol known�
Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well
, � ° _ -j�� or Bonng Constructed _.� - '
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ll r "..�t/ir: ra r.a ia : � ?�. . .
Numerical Sireet Address or Fire Number and Gty o(Well or Boring Location . { _� �
�1`� r � �` r � /'
f ,(''/J � � `, � '�.r , v'' ':� . Depth Belore Sealing ft. Original Depth ft.
A.� �-
Show exact location of well or boring Sketch map of well or boring Static Water Level �.Accurate
in section grid with�'X`. location.showing property lines, '
N roads.and buildings. ❑Approximate
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! -��'j �'Single Aquifer ❑Multiaquifer ft. � below above land surtace
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_i_ _�_ _i_ _i_ CASING TYPE
W � � � � E �l
� � � � T
_�_ _�_ _r_ _r T !<J(` . _
� i i � � 4 � �.Steel ❑Plastic ❑Tile
'%mile ❑Olher
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_i_ 'i_ _i_ '- . !'i+ � .'""_-��
��,: "! `�
S � ' - Screen from to ft Open Hole irom to ft.
r-1 mile-►{ ` \���``+„ OBSTRUCTION/DEBRIS/FILL
PROPERTY OWNER'S NAME �Obstruction ❑Debris ❑Fill
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r i' „ ! � �` j ` : ? `
Type of debris/obstruction _
Mading Address rf ddferent ihan property address indicated above.
Obsiruction/Debris/Fill removed? �Yes ❑No
' PUMP
. '....�.<,�,...
� Removed ❑Not PreseN ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space ini�ially grouted7
If not known,indicate estimated formation log from nearby well or boring. ; ,
� �
��J�/ �`y'' in.from � ' to �'� ft. ❑Yes +�f�lo ❑Yes ❑No �Unknown
in.trom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to fi. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�,,.No Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to tt. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of perforator
❑Other
GROUTING MATERIAL
� ) �
� / f = ba s
Grouting material Z - from to � ft. yards g
from to ft. yards bags
. REMARKS,SOURCE OF DATA,DIFFICULT�ES IN SEALING
��� � �� from to ft. yards bags
. , r
from to ft. yards bags
1 (. . t _ UNSEALED WELLS ANO BORINGS , ,�,-�, �� ,�
I i
9 . + Other unsealed well or boring on property? �Yes ❑No � - . -.. �,
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is
true to the best of my knowledge.
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C.
Contractor Business Name License or Registration No.
� ��__. � �_ �j' G ,
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Authorized Representative Signature Date
58088 �', � „ { - ��t
LOCAi.COF'Y H .�. ' � .
Name ol Person Sealing Well or Boring
HE-01434-01