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wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Seai ng No. ell and Boring� ��`,�:., 10 4 9 2 6 <br /> County Name WELL AND BORING SEALiNG RECORD Minnesota Uni9y �. �, <br /> Minnesota Statutes,Chapter f031 or W-series No�,� <br /> � � (Leave blank if not�d�n' <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> 4ra�so 118 23 3b �Y�38 � �` <br /> Numerical Street Address or Fire Number and City of Well or Boring Location /� � �/ j <br /> 122 �11�15T t�1i+L2� �� �as� 55391 Depth Before Sealing ��[J ft. Original Depth�7� ft. <br /> Show exact location of well or boring Sketch map of well or boring AqUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property u�gle Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. <br /> N WELUBORING ❑ Measured ❑ Estimated <br /> � � � � �fY� � ater Supply Well ❑Monit.Well � <br /> � + <br /> i � � � <br /> T -�-- --�-- --�-- � �. <br /> ___.,__ ❑ Env.Bore Hole ❑Other ��'�R. �below ❑ above land surface <br /> yy --�- -;-- --;-- --�-- E CASING TYPE(S) <br /> � � <br /> � � � �.... <br /> � �'t <br /> � � � � } �,r.'� teel ❑ Plastic �Tile ❑ Other <br /> ' j � _,.._._...._.�.�. .:.. <br /> 'k mile t . <br /> ' ' ' ' CASING <br /> -�-- -�-- ---i-- --�-- � # <br /> ; Diameter Depth Set in oversize hole7 Annualar space initially grouted? <br /> L� / <br /> p(�-1 mile� - . : � �/in.from�_ ro��p ft. ❑ Yes 14'No ❑Yes ❑No ❑ Unknown <br /> � _ ... J�� ... E� . . . �..,i`� 1� <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> m i e�s i different than well location ad ress in icate above. in.from to it. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> s ,) j <br /> Screen from�_to /�� ft. Open Hole from to ft. <br /> OBSTRUCTIO WDEBRIS/FILL <br /> WELL OWNER'S NAME �[]/Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> JS <br /> Well owner's mailing address if different than property owner's address indicated above. Type of ObstructioNDebris/Fill ��AIL/f'Ij �I�' � ,��1 <br /> Obstruction/Debris/Fill removed? es ❑ No <br /> PUMP <br /> Type��,,,,� /✓1 l�� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO emoved ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log rrom nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> j �!]/f�o Annular Space Exits <br /> �\ <br /> � � ❑ Annular space grouted with tremie pipe <br /> !f�l ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to n, ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> / <br /> GroutingMaterial , n � to��ft. yards _�_ bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOUHCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes No <br /> LICENSED OR REGISTERED CONTRACTOR CERT ICA ION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> —�M Sto�ltt1�17 ]�"i 1 jinb C.n_� _Tnc_ 27172 <br /> Contractor Business Name License or Regishation No. <br /> �,.._ <br /> ,..... , <br /> i <br /> r' . "'presen 7ive SignaWre'" � ``"" �Date <br /> __„�..,- �, _,.�..,... <br /> " ...__ �F ,. �{ :..... . .%: �.,.�_ . .: � <br /> LOCALCOPY H <br /> `� 0 4 9 2 6 Name of Persb'n`Sealing Well or Bonng <br /> HE-01434-02 10/95R <br />