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<br /> Minnesota Well and Boring ?;
<br /> - WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 3 l 0 4 9
<br />� CountyName WELL AND BORING SEALING RECORD M��nesota u��q�e No.
<br /> Minnesota Statutes.Chapter 103/ or W-series No.
<br /> p N iLeave blank if nol known� .>
<br /> \. �
<br /> Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approxima�e Da�e Well -
<br /> ,� ` or Boring Cons�ruded
<br /> ��a ��a ��a � �� �'� S
<br />�� Numerical Sireet Address or Fire Number and City ot Well or Boring Location ,,,
<br />�,.. �( I
<br />�, r r^ � �� � Depth Betore Sealing � � ft. Original Depth ��` (='�' it.
<br />�`. Show exact location of well or boring Sketch map of well or boring Stahc Water Level ❑Accurate
<br /> in sec�ion grid with��X��. loca�ion,showmg property lines.
<br /> N �tf roads.and buildings. �Approximate -
<br />,��.� i � i i_ :� , /
<br /> K ; -i i- -�- -i [
<br />& , Single Aquifer ❑Multiaquiter '��; fl. � below above land surface
<br /> ° i � i i � �" � l�
<br /> -�- -�- -�- -�- � CASING TYPE
<br />��� W i i i i E � '
<br /> k /
<br /> I 1 I I �yj
<br /> 4 � -i- -�- -r- -r � L
<br />�:_: i i i i � � f �Steel ❑Plastic ❑Tile ❑Other
<br /> :;mile
<br /> F" _i I I i_ � )
<br /> _ _ '_ _ _ _I f
<br />�: S "' "��-�.,, � i/ Screen trom to ft. Open Hole from to ft
<br /> N-�mile----� / OBSTRUCTION/DEBRIS/FILL
<br />�`=;' �Obstructlon ❑Debris ❑Fill
<br /> y, �� PROPERTY OWNER'S NAME
<br /> 3
<br /> Y ` ..,_ '..,. .: .F.�;,� ;;.�: ✓ TYPeo(debris/obsiruction + It�..3r�:,•'fJ 1 fY:,, �-�, � L.,_�;�. C. � �f=. �l- F, .
<br /> Mailing Address rf ditfereni ihan property address indicated above. a
<br />� Obstruction/Debris/Fill removed7 Yes ❑No =
<br /> �e^a't'T-(.. ;`.P' . . PUMP
<br />�.S_.
<br /> �
<br />� � ❑Removed o�Present ❑ Other
<br /> � CASING � �
<br /> HARDNESS OF ��
<br />� ; GEOLOGICAL MATERIAL COLOR FROM TO
<br /> FORMATION
<br />`' ' Diameter Depth Set in oversize hole? Annular space initially grouted7 F'�
<br /> ��: It not known,indicate estima�ed formation log from nearby weli or boring.
<br />�F� � ; q
<br /> in.from �to �� k. ❑Yes QQ�Io ❑Ves ❑No �(lnknown
<br /> /-
<br />�-����'�� in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown ��''
<br />�;=
<br />�;:�:" in.from ro fL ❑Yes ❑No ❑Yes ❑No ❑Unknown
<br /> u��::
<br />��;;; METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
<br />�-� �[l�lo Annular Space Exisis
<br />� ` "\
<br />� ❑Annular space grouted with tremie plpe �. .�: �,� ,� {�-s�- ;'�..,�- �.3
<br />�€� �� ❑Casing Perforation/Removal "�
<br /> F fip
<br /> E+��. ��
<br />� �
<br />� in.from to k. ❑Perforated ❑Removed
<br />�-,; �
<br /> � ���s in.from to ft. ❑Perforated ❑Removed
<br />�,,.�:�: '�
<br />��'`�- Type of perforator
<br /> r
<br />����- ❑Other '�
<br />�,,;
<br />�fi:.; GROUTING MATERIAL
<br /> <�
<br />�`� 'r;
<br /> tif:, �
<br />.�s
<br /> 4ri^p� Groutingma�erial���i��Y1�t.:d�! �f from ��i to �,�k. yards � <� bags '
<br /> c,:' °[
<br /> k a;p ..
<br /> �: from to ft. yards bags �,a
<br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING �'
<br /> �
<br /> from to ft. yards bags
<br /> ~ " � �
<br />��' � �,�.`��� � �,
<br /> y-n,� " ,t ' from to ft. yards bags
<br />€z� �� �
<br /> K„w.� ( � \�, � �.�,V� UNSEALED WELLS AND BORINGS t�t� � .. , � _ �`,_f �f : , `�
<br />�. .)cK:+C� Y uo G�:�
<br /> Other unsealed well or boring on property? es ❑No ,,�
<br /> rr U�� � LICENSED OR REGISTERED CONTRACTOR CERTIPICATION
<br /> . C C�G. vSIvE
<br /> �-� This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is �
<br /> �t
<br />�i„�� '` � r true to ihe best of my knowledge.
<br /> ��''MC��:V �i f:,i/�l ��!�1 S 7
<br /> , I�� ,11<.�, �; ;�G��
<br />�ix ��1� .� f,'�� � , ;��� ContractorBusinessName Licens�eorRegistrationNo. 3�
<br />�� � , �� C
<br /> �- { 4;. �=����-� �l- � �
<br /> �`�.�li,f C� �n 5 l ��� l y*� 4 y-�ri �.
<br /> ` -� Authorized Re resentative Signature � Date
<br /> . \ • \ � �/ ,�,C.� �--'
<br /> LOCAL COPY H �?: 1;.,r� r `�++.", �
<br /> t,;
<br /> Name ol Peison Sealing Well or Boring
<br /> H601434-01 �
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