Laserfiche WebLink
� <br /> Minnesota Well and Boring <br /> wELL OR BORiNG LOCATiON MINNESOTA DEPARTMENT OF HEA�TH Sealing No. H <br /> co���Y Name , WELL AND BORING SEALING RECORD Mi��eso�a u��q�e No <br /> Mmneso�a Statutes.Chapter 103/ or W-series No. <br /> ���'.,^ ✓�i:�"% �'� ILeave Dlank il nol knownl <br /> j /� I <br /> Towns�ip Name To ship No Range No Section No Fraction�sm �Ig� Date Sealed � Approximate Date Well F . <br /> � or Bonng Constructed � `� � r ' � <br /> ('?r�c�v► � �,4 �„ �,4 � —/ f' � .� ; �. <br /> Numencal Stree�Address or Fue Number and Cdy of Well or Bormg Localwn �') ^j � � � <br /> ,` OC GC <br /> f� �� ,� ��ni�,��� \ {. ! �f � ;7��,.; . ;f� epth Before Seahng ft. Onginal Depih ft. <br /> � 4 <br /> Show eKact locatan of well o�bonng Sketch map of well or bonng Stafic Water Level �Accurate <br /> in section gritl wdh��X��. location.showing property 6nes. � . <br /> roads.and byildinqs <br /> ❑Approx�mate <br /> N � <br /> ��V�:�1 --� �"� — �<. <br /> k, � Single Aquder ❑Multiaquder `f' �`l fl. —� below aboe'e land suAace <br /> � <br /> _�_ - - -- ( � n CASING TVPE <br /> w -- ; ; � � � <br /> -- -,- -r- <br /> i } �Steel ❑Plashc ❑Tlle ❑Other <br /> i i i , <br /> .mi�e � \ <br /> i i_ i i � � e <br /> -I' i ___ __ �.. <br /> ��"`"re"'--•' �" Screen irom b f1 Open Hole from to ft � <br /> �-- t Sile� , � . <br /> L..._..--------��- OBSTRUCTION/DEBRiS/FILL <br /> S <br /> �Obs�ruc0on ❑Debns ❑FII <br /> PROPERTY OWNER'S NAME �.� '�, � <br /> j� �r i -_i c� �l� � �.�rv�c� r� ��,� (,ir ,: 4: t; ��, � C � � ;::� %�t�yi�.. <br /> `�'- <br /> Type o�debns/obstruciwn ' '" �— <br /> Ma�6ng Address d ddterenl ihan propeAy address mdicated above. <br /> / Obstruchon/Debns/Fill removed? � Yes ❑No <br /> /�f t�f" / �V y � Cl SL` E/�� PUMP <br /> ��7 Z't`�' ''` ��� ���� � emoved ❑Not Presen� ❑ O�her <br /> � <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO • <br /> FORMATION <br /> Diameter Dep�h Se�in oversrze hole9 Annular space mdially grou�ed? <br /> It not known.indicate esUmaled brmation log Irom nearby well or bonng. ^^}} ,,.�.) <br /> jZ� � � in.from �to(7�L]t. ❑Yes �No ❑Yes ❑No �Unknown <br /> �� <br /> m.from �o R. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.irom to ft. ❑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 grou�ed with tremie pipe <br /> ❑Casing PeAoration/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> m.irom to ft. ❑PeAorated ❑Removed � <br />� Type ot pertorator <br /> ❑Other <br />�.� GROUTING MATERIAL <br /> t 'T <br /> f t 1. V�i/ �Y r, ..{, t �r^� � ''") <br /> �.. <br /> Grouting material t -L���� 4 �ti' ' 11�� from b�✓ to �^' y �ft. yards �bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to R. yards bags <br /> from to it. yards bags <br /> UNSEALED WELLS AND BOHINGS <br /> Other unsealed well or boring on property7 ❑Yes No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The informat�on contained�n this report is <br /> - true to ihe best of my knowledge. <br /> �� ,� � ( � �. <. � .��� C� �� <br /> � �Contractor Business Name � License or Reg�sfrafion No. <br /> `�� � . j <br /> �!, , �'�. , / _ •' j . <br /> 1 t "- J <br /> Aufhirzed Rep�esentahve SignaNre Dafe / <br /> � <br /> f=f <br /> ." %' . .�. ,�_.� . ;��r <br /> ����� H �5�3� Name ol Person Sealrng Well oi Bonng <br /> HE-01434-01 <br />