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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 110 0 5 9 <br /> WELI OR BORING LOCATION <br /> CountyName WELL AND BORING SEALING RECORD Sealing No. <br /> Minnesota Unique No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (- �\,f (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date bYell or Boring Constructed <br /> , r' <br /> '/a / '/a �, _ A C:,� :�� ���f � � . <br /> � <br /> Numerical Street Address or Fire Number and City of Well Borin Location <br /> t ; j' <br /> �. � � , � � � Depth Betore Sealing � ' ft. Original Depth (� ft. <br /> .-: <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 Single Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. �O <br /> ry WELUBORING [�Measured ❑ Estimated V �' � , <br /> ' ' ' ! ;�,. � �'';. N � � ['�,'Water Supply Well ❑Monit.Well ��� ���� <br /> � i ., . � <br /> - -r- - - --�-- -- _.—". � <br /> r � — <br /> I � � � �"�--- ❑ Env.Bore Hole ❑Other ft. �below ❑ above land surface <br /> W --�- -�-- -'-- --";-- E N�1'� � CASING TYPE(S) <br /> � i <br /> i _.�^—��� <br /> � � � � J <br /> —�- -�-- -�-- ---I-- �,,. j';`'� [�„Steel ❑ Plastic �Tile ❑Other <br /> � � � '/mile �P h1_'j <br /> ' ' ' ' � - i CASING <br /> —�- -�— --�-- ---I-- � � <br /> � � � _...__, <br /> t Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> I� S �J� �� in.from�_ to �� ft. ❑ Yes [�No ❑ Yes ❑ No �Unknown <br /> pk—1 mile�ie —..v <br /> I I <br /> PROPERTY OWNER'S NAME _ in.from to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown <br /> z <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> � �-r'�k <br /> �'� - � Screen from to ft. Open Hole from to ft. <br /> OBSTR UCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME r �'Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> ', �`-1 . � <br /> � � � � <br /> Well owner's mailing address if di8erent than property owner's address indicated above. Type of Obstruction/Debris/Fill 1 �� ' t_�+ ! �- .1 �. <br /> Obstruction/Debris/Fill removed? Yes ❑ No <br /> PUMP <br /> TyPe i � <br /> 3 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed [y`� Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby wall or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � No Annular Space Exits <br /> 1� <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.trom to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material �,� �'� �'i�. �' from (: , 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 BORWGS �, ., : k.. �� � . <br /> � �,}� t` . <br /> Other unsealed well or boring on property? Yes ❑ No <br /> �1 LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> ��'` �. <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 /> i <br /> � �t` ��{ . ��� � : �. � f!.,,1 <br /> Contractor Business Name License or Registration No. <br /> , 1 j, .�/\. 1,,, ._ ,�{ <br /> Authonzed Representative Signature Date <br /> ;-,�{� <br /> ` , ' ; E `• , , �f'. . 1 <br /> 1 <br /> o� � Name ol Person Sealing Well or Bonng �� <br /> LOCAL COPY H ! � O �..� � � <br /> HE-01434-02 10/95R <br />