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Minnesota Well and Boring �� <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEAI.TH Sealing No. H 2 9 0 4 4 �� <br /> i:: <br /> �o���Y Name WELL AND BORING SEALING RECORD M���esota���q�e No ,�� <br /> Minnesota Statutes.Chapter 7031 or W-series No. '� <br /> ����� ILeave blank if nol knownl <br /> ( � ':i <br /> Township Name Township No. Range No. Section No. Frection(sm. •Ig.) Date Sealed Approximate Date Well `4 <br /> � y �F, y �� ��„ or Boring Consiructed / '' �� � <br /> !C�� •� �1 .. ��a �ra �ia ? ... ! ,�� : V .� � <br /> Numerical Street Address or Rre Number and City o(Well or Boring Location � ,-r�y�� � � <br /> s"' � �+ ' Depth Before Sealing � � � (L Original Depth L' C� ft. � <br /> Zf:. �Ae.r:� -'r � �. <br /> Show exact location of well or boring Sketch map ot well or boring Static Water Level �Accurete 1� <br /> in section grid with��X'�. bcation,showing property lines. � <br /> roads.and buildings. ❑Approxima�e -�.� <br /> N �_ `� <br /> i i i i �-.,_..._.- <br /> _i_ _i_ _i_ _- . /� <br /> � Single Aquifer ❑Multiaquifer ���-' fL � below above land surface <br /> i i i i � <br /> -i- -a- -i- -�- .,,` CASING TVPE � <br /> W i i i i E ,`� <br /> �i. � <br /> � � � � � <br /> -�- -,- -r- -�- .�r� � <br /> i i i i ..� l 1 � Steel ❑Plastic ❑Tile ❑Other � <br /> n mile <br /> _i i i i_ � '.� L.�^r� ..-�� . <br /> i_ _ i_ _i _ _i � .,� <br /> .'� ' � <br /> t� � j Screen from to ft. Open Hole from to ft. _�Y� <br /> �7 mile � <br /> � L._�', OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME �Obstruction ❑Debris ❑Fill � <br /> J / � <br /> r; y�,/t �� {.� ✓ F�J �� � �ti.i � � ��i_t� � �( ��E�`��' rr ��� ` iJl.���i� � <br /> '� �! Type ot debris/obstruction - - .y' <br /> Mailing Address it ditferent ihan property address indicated above. �:. <br /> Obsiruction/Debris/Fill removed? �,,Yes ❑No � <br />�-- � <br /> : � <br /> - PUMP <br /> :,µ <br /> t" � <br /> ,_? ,...,`M ` � <br /> Y—� <br /> - � Removed ❑Not Present ❑ Other <br /> � CASING � <br /> E - � <br /> HARDNESS OF <br />¢=,�c. GEOLOGICAL MATEFIAL COLOR FORMATION FROM TO ,,� <br /> Diameter Depih Se�in oversize hole? Annular space initially grouted? ''� <br /> 4� If not known,indicate estimated formation log irom nearby well or boring. <br /> � �� s <br />°^� � / in.from `~' to � fl. ❑Yes �No ❑Yes ❑No �Unknown <br />��', � f <br /> n=. <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br />� <br /> ' in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br />�.k'Y. <br />� � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br />�'�'�� �No Annular Space Exists <br />`;_:� ❑Annular space grouted with tremie pipe <br /> s£; <br /> ❑Casing Perfo�ation/Removal <br /> '?.; <br />�-. � <br /> �;9 <br /> in.from to fl. ❑Perforated ❑Removed »:� <br /> in.from to ft. ❑Perforated ❑Removed ': <br />�� � <br />�i,%� <br /> r. <br />��:`�' Type of perforator ��� <br /> F: 3' <br />� � <br /> ❑Other <br />� ;� � <br /> GROUTING MATERIAL <br /> (./ +l <br /> - Grouting material '�. '���'�'��.5+-�t� from �' to � ' fl. yards � bags � <br /> y..._ <br />?.'�: 5.� <br /> � from to tt. yards bags � <br />�� � <br />���� REMARKS,SOURCE OF DA7A,OIFPICULTIES IN SEALING <br />�F � <br />�,. irom to ft. yards bags <br /> i <br /> " �--� �J� �t � C,`; � vt c..: <br /> . -_.! trom to ft. yards bags � <br />�,' � <br />� ' , UNSEALED WELLS AND BORINGS ;� <br /> � <br /> 1 �--� V e ' ' � � :� Other unsealed well or boring on property? ❑Yes No �'� <br /> } '; �} <br /> K'��=" <br /> � LICENSED OR REGISTERED CONTRACTOR CEHTIFICATION �,� <br /> ` '- This well or boring was sealed in accordance with Minneso�a Rules,Chapter 4725.The information contained in this report is � <br />��._ ' ���,� 'S`j ��r � �.'� �;t� L, true to the best of my knowledge. � <br />� _ 4 � , 1i r; 1'�, � jz/ � <br /> . . , � <br />��,;� `; � . ��� Contrector Business Name License or Regisfration No. �� <br /> � ( }, � ( '� <br /> "�,. .. . � r' <br /> r! , , l 4'''G��� !' _._ /.� S� <br /> Autho zed Representative Signature -- Date � <br /> � � 1 # �` 1�'' <br />.. LOCAL COPY u . �� � � '� <br />�; n Name ol Person Sealing Well or Boring . <br /> -�; HE-01434-01 <br />