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'�� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 5 6 9 8�
co���Y r�ame WELL AND BORING SEALING RECORD Mm�esoca uniq�e rvo.
+ — i�T1I1. Minnesota Sta�utes.Chapter 1031 or W-series No.
ILeave blank il not knownl
Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well
^� ��� t�� or Boring Consiruded
1� f �� LSV ��ti�[9� �ra ��
Numerica treet Address or Fire Number and City o(Well or Boring Location � j
5J7 �C1�.tC �. C�rC.�{1 J5356 Depth 8efore Sealing /�� ft. Original Depth j�� ft.
Show exact location of well or boring Sketch map ot well or boring S[atic Water Level ccurate
in sedion grid with'X". ;. /'� location.showing property lines.
�J ��i'.,., roads,and buildings. ❑Approximate
:� ���
N
_� i i �_ __.'.� � # � �
i_ ___ _i_ _i �3i:,, �
�,ry '��� q � =- ingle Aqwfer ❑Multiaquifer �ft. � below above land surface
i � i i � � �
_i_ _�_ _i_ _i_ ; CASING TYPE
W i i i i E � �
i i i i \ � ��
-i_ _�_ _r_ _i- ..\}. ••
i i i i �e ��e _s �, teel ❑Plastic ❑Tile ❑Other
i i i i � .
-i - i- -�- -i � � � /
S � � � Screen from � to � ft. Open Hole from to ft.
�--1 mile—� 1.,;�'� OBSTRUCTION/DEBRIS/FILL
❑Obsiruction ❑Debris ❑Fill
. PROPERTY OWNER'S NAME
LA.R.; c- t�,t�.it.... ����
Type of debris/obstruction
. �� Mailing Address d diflerent than property address indicated above.
Obstruction/Debris/Fill removed? ❑Yes ❑No
j PUMP
{ � �� _ '�+/� ° `__ � !
4 ❑Removed ot Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diame�er Depih Set in oversize hole? Annular space initially grouted?
It not known,indicate estimated formation log from nearby well or boring. ,� ,
}��,i .L j��'� [ (t�-.,' �in.from �to L.SdQ fl. ❑Yes J�VJo ❑Yes ❑No ❑Unknown
tl � v t t;
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.(rom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
OCNo Annular Space Exists
��
❑Annular space grouted with tremie pipe
� ❑Casing PeAora�ion/Removal
� - ' in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type ot perforator
❑Other
� GROUTING MATERIAL
w f
Grou�ing material�/'��.'��� �'��`�� irom �_to �ft. yards �_bags
from �o ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to fl. yards bags
from to ft. 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 information contained m this report is
Vue to the best of my knowledge.
Lbn Stcx;r;l.a hlell Dri11�.x�g Inc. G'i 1 i�
Contractor Business Name , �� :- �' License or Registration No.
,�'' : ` ��
. �
__ , . , � .
� . : ,
r �` �< „e�- .
o epresentative Signature Date
� � �
LOCAL COPY H �,J��V� �� ' r � �'�� � �' � _� � I_
Name ol Person Sealing Well or Boring
�� HE-Ota34-01
Minnesota Well and Boring Q
� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 5� ..J 8 t �:
�o���Y Name � WELL AND BORING SEALING RECORD M���esota u��q�e No.
. �("��1 , Minnesota Statutes.Chapter 703/ or W-senes No.
(Leave blank if nol known)
�� Township Name Township No. Range No. SecUon Na Fraction(sm. �Ig.) Date Sealed Approximate Date Well �
� or Boring Constructed
( } � � � G � C�-,t,,r,, q`��.� '�,,. ',4 �.
Numencal Street Address or Fire Number and City of Well or Boring Location � � �
t"'���� ��� � � L� �� �"-�-•,_,� Depih Before Seahng �� ft. Original Depih �� fl.
l
Show ezact Ixation of well or bonng Sketch map of well or boring Static Water Level �.ccurate
in section grid with"X��. � location showing property 6nes.
_ N `-,/ � � f roads.and buildmgs. ❑Approximate
�V
'.{, ,
-� '�- "�" "� f'� _ � g q ❑Multiaquifer �tL � below above land surface
i i i i (-'.
.r ''�1 in le A uifer
_i_ _�_ _i_ _i_ j r�- �r�"`. CASING TYPE
W � � � � E }� �7i �•
� � � � T �
-r -7- -r- -r
� � � � T � teel ❑Plastic ❑Tile ❑Other
a mile
� i i i �
_i_ _ i_ 'i _ _- � . I J
S r t Screen from� to � ft. Open Hole irom to ft.
.+
N--t mi�e�I '� � � � OBSTRUCTION/DEBRIS/FILL
bsiruction ❑Debns ❑Fill
PROPERTV OWNER'S NAME
_. '� . � r.—:�-� -�
r� �� �( , � � �� `���� Type ot debris/obstrudion ��r/l,�f f(7 f�f�� s J�r
� Mailing Address drfferent than property address indicated above.
ObsVuctioNDebris/Fill removed?�Yes ❑No
i /� PUMP
� _,# ;-_ .�.;� i 4 �
❑Removed ot Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole7 Annular space initially grouted7
If not known,indicate estimated tormation log from nearby well or bonng. �
i/ s�
.�- /'� '�in.from �-+� to � ft. ❑Yes �Vo ❑Yes ❑No ❑Unknown
t,}
� in.irom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑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�remie pipe
❑Casing Per(oration/Removal
in.from to ft. ❑Perforated ❑Aemoved
in.from �o ft. ❑Perforated ❑f7emoved
� Type of perforator
❑Other
GROUTING MATERIAL
� ... /�� 1
Grouting material/���� C'���✓����from (.J to �ft. yards �bags
from to fl. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
from to h. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑Yes o
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 ihe best of my knowledge.
z 1
�: �1 I�ri ,�"1 C- �1 �}iFi';,',i: J�i��' GG, 1 � 7�
Contractor Business Name J License or Registration No.
/ / / � �
..l�/ /��! - � �..q ��„L��-., j�� ... ��` ,..li�
Aut zed�Representa6ve S�gnature Date
LOGAL GOPY H V��V� �, T 1 ��, i � i` t._�,'�!�
Name o/Person Sealing Well or Boring
HE-01434-01