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Minnesota Well and Boring <br /> WELL OR BORING LOCATiON MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD M���esota u��q�e No. � <br /> Mmnesota Statutes.Chapter 1031 or W-series No. <br /> /� � � ILeave blank it nol known� <br /> Township Name Township No Range No Section No Frachon(sm. •Ig� Oate Sealed Approximate Da�e Well <br /> �`�,4 _ Y or Bonng ConsVucted / � ,;��, <br /> 1 ✓, y�.) �i4 �14 �ia . �.�., . _i'✓ <br /> Numencal Stree�Address or Fue Number and City o�Well or Bor�ng Locahon , j <br /> —r � ` <br /> f k)� Depih Belore Sealmg �� � � fl. Original Depih "�"� `� ft. <br /> � �. r a v�in <br /> Show exac�localron of well or bonng Sketch map ol well or bormg Sta�ic Wa�er Level ,�Accurete <br /> �n section gnd wAh�X�� locatwn,showing property hnes. <br /> roatls.and bwldings ❑Approximate <br /> N <br /> 1 ) � �. <br /> -- --- --- -- �yN yn� k.� �-, �.. r,�' <br /> � � � � '\� '��- �Single Aquder ❑Multiaqwfer fl. below above land su�face <br /> i i i i <br /> _�- -�- -i- ��� CASING TVPE " <br /> W i ; i i T ( <br /> _ _r_ _' <br /> i i i ,'_k �Steel ❑Plastic ❑Tile ❑O�her <br /> -- - �- -�- -�- ,� .`.� <br /> _ i <br /> S �� Screen irom to fl. Open Hole irom to R. <br /> �—�'^'k� OBSTRUCTION/DEBRIS/FILL <br /> �Obslruction ❑Debns ❑Fill <br /> PROPERTV OWNER'S NAME <br /> ,�;�i � �._ f. , � , ,< � j � � <br /> Type of debns/obsiructwn - � � <br /> MaJing Address d ddferent than property address indicaled above � ' <br /> Obsiruchon/Debns/Fill removed? �Yes ❑No <br /> PUMP <br /> :hf ,r.r; ti; <br /> Removed ❑Nol Presen� ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COIOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space mAially giouted7 <br /> II not known,ind�cale esfimated formation log irom nearby well or bonng. <br /> �/ �� <br /> � `� in.from lo � '� '� It. ❑Yes �o ❑Yes ❑No �'J.Jnknown <br /> m.irom to fL ❑Ves ❑No ❑Yes ❑No ❑Unknown <br /> in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <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 iremie pipe <br /> ❑Casing Pertoration/Removal <br /> in.from to fl. ❑Pertorated ❑Removed <br /> m.irom to fl. ❑Pertorated ❑Removed ' <br /> Type of pertorator <br /> ❑Other <br /> GROUTING MATERIAL <br /> Grouting material�`.'r:�,� � � i C� irom �to ��� ft. yards (l bags <br /> from to N. yaids bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> '� � ! from to fl. yards bags <br /> � l�.le �� - .� <br /> from to ft. yards bags <br /> � !`i �`J���' , f � !�"� UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on propeny? ❑Yes �(No <br /> _ a,,. , _ . . LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed m accordance with Mmnesota Rules.Chapter 4725.The mformation contamed in this report is <br /> true�o ihe best of my knowledge. <br /> � 1! a „' (' (y! <br /> ! ��- . � ' i� ,.ri- 1 <br /> Contractor Busmess Name L�cense or Reg�stra6on No. <br /> � � l _��•,N`` t� ...„ � ' <br /> Authonze epresenfafive Signature Date <br /> N � -�' i^.`1 � �)v u ✓. `� r�✓ <br /> �Q�.w',[.�L.,�,7.W'v7 •• ` � Name ol Person Sea6ng Well oi Bormg <br /> HE-01434-01 <br />