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Minnesota Well and Boring 2 8 8 3 9 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> co���v Name WELL AND BCSRING SEALING RECORD Mi��esoca u�iq�e No. <br /> � F._'—__� Minnesota Statutes.Chapter 103/ or W-series No. <br /> jjp�gpi7 �Leave blank it noi knownl <br /> �----r <br /> Township Name Township No. Range No. SecUon No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br /> �A ��� � � 4 4 �� � �� � �,y f or Boring Constructed <br /> VL1Jlii <br /> Numencal Streel Address or Fire Number and City of Well or Boring Location {�' t, <br /> 323S C+�sco Circle � �rp Cii� SJJs� Depth Before Seahng '''"� ft Original Dep�h "'� ft � <br /> Show exact location oi wetl or bonng Sketch map o(well or boring Static Water Level Accurate <br /> in section gnd with�X loca�ion.showing property lines. <br /> roads.and buildings. ❑Approximate <br /> N � <br /> � i i � `J <br /> -,- - - - - -,- >> 7� <br /> �1.� Single Aquifer ❑Mulhaqwfer fL ' ` below above land surface <br /> i i i i 7 �.�� <br /> _i_ _�_ _i_ _i_ CASING TYPE <br /> W i i i i E '� <br /> � � � � <br /> -r -�- -r- -r .' <br /> � � � � �n mi�e Steel ❑Plastic ❑Tile ❑Other <br /> _i i i i_ � v <br /> i_ _ i_ _i _ _i . <br /> Screen from `��'`'� to —�+� ft. Open Hole from to fl. <br /> S r ?� <br /> �--i mi�e—� -��� �� � OBSTRUCTION/DEBRIS/FILL <br /> PR�7p ER Y NER'S NAME �i3Obsiruction ❑Debris ❑Fill <br /> V�������'.� <br /> ^�,, <br />/ Type of debris/obstruction �'� �� �� � ' F' �^' �'V " �-� <br /> Maihng Address if different than property address indicated above. �� <br /> Obsiruction/Debris/Fill removed? Yes ❑No <br /> PUMP <br /> r <br /> ❑Removed ' Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depih Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate es6mated tormation log from nearby well or boring. <br /> �� O � �in.irom �' to �"�- fl. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> in.irom to ft. ❑Yes ❑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 Exisis <br /> f <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to fl. ❑Perforated ❑Removed <br /> in.f�om to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑O�her <br /> GROUTING MATERIAL <br /> i'•.; j <br /> Grouting material ti��'----' l.'� ��' from �-� to ��'�'� ft. yards �bags <br /> irom to fl. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> irom to fl. yards bags <br /> C+Sro�ited 2" vell 66' deep <br /> � � C�it from to fl. yards bags <br /> N � L�iItVliiLe UNSEALED WELLS AND BORINGS <br /> f � <br /> 2 � �$����g a{ �t �jt ��) Other unsealed well or boring on property? ❑Yes No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATI N <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The intormation contained in this report is <br /> true to the best of my knowledge. <br /> Dcm Stcx3ola Well. DriIl3x�g Cc�., Iz�. 27I72 <br /> Contractor Business Name License or Registration No. <br /> �.. ,,..;�<`f'' _ - E3"��� <br /> ��'�..-�''� c' - - <br /> A-L�n�d Representative Signature Date <br /> `°�r'`���Y " 2 8 8 3 9 �' � <br /> Name ol Person Sealing Well oi Boring <br /> HE-01434-01 � <br />