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we��oR soRiNG�oCarioN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> Cou, Name <br /> WELL AND BORING SEALING RECORD Sealing No. H 110 710 <br /> Minnesota Unique No. <br /> � % _: Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank ii not known) <br /> T sh}�'p Name Township No. Range No. Section No. F�tion(Srn.��.) Date Seale Date Well or Boring Constructed <br /> �` �`� / � ttf �/'' !� l r 1 <br /> ° ��r <br /> Numerical Street Address or Fire Number an City of Well or Boring Location <br /> . � } �1 <br /> / '7 {; 1.��-" Depth Before Sealing ��� ft. Original Depth ft. <br /> f / <br /> Show exact location of well or boring Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL <br /> in section gnd with"X". location, showing property t�gingle Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. <br /> N WELUBORING �.Measured ❑ Estimated <br /> �Water Supply Well ❑Monit.Well <br /> _T_ _T_ __ __ __ __ f•-•. �' <br /> ❑ Env.Bore Hole ❑Other •-- � ft. -�below ❑ above land surface <br /> � � i � <br /> i � � <br /> W --r- -�-- --i-- --�-- E CASING TYPE(S) <br /> -- -�-- -�-- --i-- � �Steel ❑ Plastic ❑Tile ❑Other <br /> '/.mile <br /> ---- -�-- --�-- --�-- � CASING <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> S "��J"� C f ��' <br /> �t mi�e-�e � in.from � to� ft. ❑Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> I <br /> PROPERTY WNER'S NAME � in.from to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> Properly owneys mailing a�ss i�� i � ��than well location a ress indicated above. in.from to ft. ❑ Yes ❑No ❑Yes ❑ No ❑ Unknown <br /> ���; ��/� <br /> ��_ _ �,J� �. // „�,.,�.�-L^ SCREEN/OPEN HOLE <br /> . �� �l r Screen from T_to��}_ ft. Open Hole from to ft. <br /> OBSTRUCTIO WDEBRIS/FILL <br /> WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if diHerent ihan property owner's address indicated above. Type of Obstruction/Debris/Fill <br /> Obstruction/Debris/Fill removed? ❑ Yes ❑ No <br /> PUMP <br /> TYPe � � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � RemiQ�ed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ❑ No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ 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 f:. �' ��� to � : ft. yards bags <br /> �. , ,.,L�. t.{., Y� <br /> . from to R. yards bags � <br /> c <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 well or boring on property? ❑ Yes Q 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 /> .a� �---� - , _, / ` <br /> C t�c YBy�ine i�fa" - � �'-`<_ Licens or gi h . . <br /> , <br /> � f : <br /> � , � <br /> � i ; . <br /> , . J/. <br /> , . �.. <br /> .�:,' _=�i .�:'r� ., f, . <br /> / � <br /> th6" _ �gnatu ' bate <br /> ♦.,..� . ./ ri <br /> ! -,r' <br /> f!�'�.�ii g �� � �;' �: <br /> �e-'�� . .,or Boang�-�� <br /> LOCAL COPY H �_ � � � � O <br /> HE-01434-02 10/95R <br />