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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 4 9 6 3 <br /> Counry Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique No. <br /> Minnesota Statutes,Chapfer 1031 or W-series No. <br /> (Leave blank it not known) <br /> ow s p Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> � 'e '/a <br /> Numerica treet Address or ire Number an ity oi e 1 or Boring ocation � � <br /> r, Depth Before Sealing ��Sp ft. Original Depth �"S�_ft. <br /> Show exact location wel or bo g Sketc map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". j location, showing property Single Aquifer ❑ Multiaquifer <br /> t lines,roads,and buildings. <br /> N � WELUBORING ❑ Measured i�Estimated <br /> Water Supply Well ❑Monit.Well <br /> 7� <br /> _T_ __l__ __l__ � � <br /> I i � � ' �i <br /> ❑ Env.Bore Hole ❑Other ft. elow ❑ above land surface <br /> __r_ _Y_ _l__ __l__ <br /> yy E /�/,j CASING TYPE(S) <br /> --�- -r- -�-- --�-- � � Steel ❑ Plastic �Tile ❑Other <br /> Y mile <br /> -�-- -�-- -�-- --�-- � ,._�_.�.._.,, �;.�....��c.�� CASING <br /> � S � �� � Diameter,' Depth � Set in oversize hole? Annualar space initially grouted? <br /> lll""" ""�J�� i •-T'-'-'.�_ �,,(' <br /> �w--i mi�e-�e +`/��.;;;i;+ � � in.from� to��. ft. ❑ Yes �IVo ❑ Yes ❑No ❑ Unknown <br /> I I f � T� <br /> PROPERTY OWNER'S NAME _ in.from to ft. ❑ Yes ❑ No ❑Yes ❑No ❑ Unknown <br /> �o o ner' ddress if different than well loc o� ad e s n icated above. in.from to ft. ❑Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> 1 Ot Z SCREEN/OPEN HOLE <br /> Screen from��to , ft. Open Hole from to ft. <br /> 08 S T R U CT I O N/D E B R I S/F I L L <br /> WELL OWNER'S NAME �Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address it difterent than property owner's address indicated above. Type of Obstruction/Debris/Fill ��r(1/tJ«T�f-1'" �. /"r!J/yJ/'-� <br /> Obstruction/Debris/Fill removed? Yes ❑ No <br /> PUMP <br /> Type�/Ji�r�/�1� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �/fJo Annular Space Exits <br /> ; a <br /> LJ�Annular space grouted with tremie pipe <br /> `� ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft, ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> / <br /> Grouting Material v p from �_ to 1�� ft. yards �� bags <br /> i��,w <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to R. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes o . <br /> LICENSED OR REG�STERED CONTRACTOR CERTIFI AT ON <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 /> Conf�actor usmess ame License or Registrati . <br /> �,.�' � IVl - __.._ ''_ ' _. , . <br /> �i�� : � � �j . �. „� ���� <br /> o e resent2��S�gnat� Date <br /> ._._....r^^" . <br /> . `�c."`.". <br /> �y Name vf P�rson Sealin Well or Borin � ��''c ' , 4. <br /> LOCAL COPY H f 0 t�. � � � 9 9 <br /> NE-01434-02 10/95R <br />