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wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> CountyName WELL AND BORING SEALING RECORD Sealing No. H 10 6 6 7 3 <br /> Minnesota Unique No. � <br /> ��jZi1 Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Fange No. Section No. Fraction(sm.-s Ig.) Date Sealed Date Well or Boring Constructed <br /> t7ronr 31 J 2 i p7 � � � ,� <br /> Numerical Street Address or Fire Number and City of Well or Boring Location � <br /> �((�) j1](jY'�t;r.��jr�.a ��� ��� �.c��j� epthBetoreSealing ��_ ` ft. OriginalDepth �_R. <br /> Show exact location of well or boring Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property . ingle Aquifer ❑ Multiaquifer <br /> �„_` lines,roads,and buildings. <br /> N ELUBORING ❑ Measured �stimated <br /> � � � � 1�JIOater Supply Well ❑Monit.Well <br /> -- - - -- -- -- -- - 7L ! <br /> ❑ Env.Bore Hole ❑Other �ft. �below ❑above land surface <br /> W --�- -�-- --�-- --�-- E CASING TYPE(S) <br /> � � <br /> ,._.,._.......�_._ <br /> � � � ` ' <br /> --�-- -�-- -�-- --�-- � � teel ❑ Plastic ❑Tile ❑ Other � <br /> � � � � '/<milek <br /> -'-- -=-- --�-- --�-- � � CASiNG <br /> � � � � . � Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> �w--t mi�e�, � ���"��t " � �sin.from� to��ft. ❑Yes �o ❑ Yes ❑No ❑ Unknown � <br /> PROPERTY OWNER'S NAME ^ in.trom to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> ��.�laerlar�G Buililer� <br /> Property owner's mailing address if different than well location address indicated above. _ in.f rom to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> 1�,)�37 �J]„j,'[��Z� �'�,�,(� SCREEN/OPEN HOLE �� <br /> B���'���r �' S��'��' Screen from���to�� it. Open Hole from to ft. <br /> 6�3-1,�i��i'� OBSTRUCTIOWDEBRIS/FILL <br /> WELL OWNER'S NAME �bstruction ❑ Debris ❑ Fill ❑ Na Obstruction <br /> Well owner's mailing address it diHerent than property owners address indicated above. Type of Obstruction/Debris/Fill ,�(,/����`����/�'d��� <br /> Obstruction/Debris/Fill removed? es No <br /> PUMP 1 <br /> TYPe�,���R� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO emoved ❑ Not Present ❑ Other <br /> FORMATION . <br /> If not known,indicate estimated formation log from nearby weli or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> o Annular Space Exits !' <br /> �� , . �� - Annular space grouted with tremie pipe <br /> ._. �.' <br /> i� ` ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material � �(pf�_� to��ft. yards � bags <br /> from to ft. 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 welf or boring on property? ❑ Yes o <br /> LICENSED OR REGISTERED CONTRACTOR CERTIF C ON <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 /> TY��1 4'fifliYT_t.l WC.TY_ �c��y�a ��—� � <br /> Cont�actor Bus�ness Name Lic n e oR �g�strahon No. <br /> � <br /> iyi��.-. ✓' ,�'� � <br /> eArdN6 ature •--`�� -'G� Date <br /> _.r--- ; <br /> f �L� ,� <br /> ti <br /> Name ol Person Se`&ttng Well oi Boring � <br /> LOCAL COPY H � � �j �j �f � <br /> HE-01434-02 10/95R <br />