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WELL OF BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
Counly Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No.
Mmnesota Stalutes.Chapter 1031 or W-senes No.
2.Yw...«.. � ILeave blank A not known�
78GS311C:
Township Name Township No Range No Sechon No Fraction(sm �Ig� Oate Sealed Approximate Date Well
or Bonng Constructed
Urono 117 23 Z � � '��
Numencal Slreel Address or Fve Number and CAy of Well or Bonng Location t,�)� `
2655 Shad R,(� Depih Before Seahng f J`-� fl Onginal Depih ��� fl.
SFaw exacl locatan ol well or bonng Skelch map of well or�bonng StaGc Water Level Accurate
in sec��on gnd wdh��X- locatron.showmg propert hne5.
roads.and bu dings. ❑Approwmate
N
-�- - �- --- -�- �\ `� � �(
i -
� ingle AquAer ❑Mulhaqwfer . fl. '` below above land suAace
i i i i �
-I- -�_ _i_ _�_ � CASING TVPE
W � E .t�
� � � �
-- -,- -r- -�-
i i i i � � ���� Steel ❑Plashc ❑Tlle ❑Other
mrle
__ _�' _i_ _i_ � �;� / � /
7`� ��/ / '�)
S Screen from—f---F-�O--- to �— ft. Open Hole irom to ft.
��^"k� - OBSTRUCTION/DEBRIS/FILL
Obstruclion ❑Debns ❑Fill
PROPERTY OWNER'S NAME
Patrice Eller - i.�� L,P t=�1�iG � 7f i'"�
Type of debns/obstructwn z --� L
Ma�ling Address d ddterenl than property address indicaled above
Obsirudwn/Debns/Fill removed7 es ❑No
PUMP
emoved ❑Not Present ❑ Other—,��`� �U�r
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diame�er Depih Set in oversize hole7 Annular space irntially grouted7
If not known.mdica�e esGmated IormaUon log from nearby well or bonng.
i/ �
� . � m.from �_to � fl ❑Ves �p ❑Yes ❑No ❑Unknown
f, ,_
in.irom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown �
in.irom to R. ❑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 tremie pipe
❑Casing Perforation/Removal
m.irom to ft. ❑PeAora�ed ❑Removed
m.from to ft. ❑Perforated ❑Removed
Type of peAorator
❑Other
GROUTING MATERIAL
Grouting ma�enal��16�J`C�L ^from �to �Sp� yards �bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
(rom to ft. 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 informa�ion contained in this report is
M2 6 ,�g r, Irue to the best of my knowledge.
p�`( Dcm S'iodola tzTell 1)rillin� Co., iP3c. 27172
Confractor Bus�ness Name �„ L�cense or RegisVa6on No.
�,��. -� _ � -- 1 �� ��.`_
r
A�e epre entativ�e " Dafer
--�._i, . . ,. ,, �[/.. �.'x ..�
�.,�,�,;;,,((°„��7"�Y � � � ` � - � Name ol Person Sea6ng Well oi Bonng
HE�01434-01