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Minnesota Well and Boring � <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 2 9114 i <br /> �����Y Name WELL AND BORING SEALING RECORD M�nneso�a���q�No � <br /> 1 Minnesota Statutes.Chapter 103/ or W-series No. <br /> r—��'y��rl� fLeave blank il not knownl $�, <br /> ;ti <br /> Township Name Township No. Range No. Section No. Fraction(sm. •Ig.) Date Sealed Approximate Date Well �� <br /> � or Boring Constructed � � ���" <br /> v o,.�a ',a '�a ',4 �' ll' / �1 �� /�/y � <br /> Numerical Street Address or Fire Number and City o(Well or Boring Location ��.� <br /> r ti F- .,�j �.. <br /> �� (,' � �� , F�� l �� ���G Depth Before Sealing it. Original Depih � � iL � <br /> i\ <br /> a <br /> Show exact tocation of well or boring Sketch map of well or boring Static Water Level �Accurate �._."z�. <br /> in section grid with��X��. ,bcation,showing propehy lines. �� <br /> N roads.and buildings. ❑Approwmate '�`� <br /> _� � � �_ Lo„�q L ,,ek;, � 7 � <br /> � ��' '�� �� �,Single Aquifer ❑Multiaquifer -� ft. � below above land surtace ��« <br /> � � � � lJ:.'� <br /> _i_ _�_ _i_ _i_ � CASING TYPE �`� <br /> W i i i i E � ., <br /> � <br /> � � � � � i <br /> -i- -�- -r- -i- � � <br /> � � � � � �Steel ❑Plastic ❑Tile ❑Other r�� <br /> h mile _� <br /> _i i i i_ � � � <br /> i i i i �� <br /> S . _ - Screen from to ft. Open Hole from to ft. � <br /> �-7 mi�e--►I ,� I OBSTRUCTION/DEBRIS/PILL <br /> PROPERTY OWNER'S NAME �Obstruciion ❑Debris ❑Fill � <br /> { % <br /> ' ! �1 • r � •��°- � ... ,,,.,. �C�c, t�:�, � !�i l, ' t •� <br /> Type of debris/obstruction -� '� � � <br /> Mailing Address i(differcnt ihan property address indicated above. � <br /> Obsiruction/Debris/Fill removed? Yes ❑No <br /> PUMP � <br /> _ {-i <br /> � •, �.�- ,.. ;i <br /> � ❑Removed ,�Not Present ❑ Other � <br /> � � <br /> CASING � <br /> ''9 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION "� <br /> Diameter Depth Set in oversize hole? Annular space initially grouted9 -� <br /> It�not known,indicate estimated formation log from nearby well or boring. � <br /> .A � � 'a in.from �'� to �7 fL ❑Yes �No ❑Yes �No ❑Unknown ����:';a <br /> �\/ <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown ,�j <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> ;* <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �� <br /> �No Annular Space Exisis <br /> ❑Annular space grouted with tremie pipe <br /> �.--�' _ <br /> . ❑Casing Perforation/Removal <br /> Cii= F,'l <br /> � � � � in.from to ft. ❑Perforated ❑Removed <br /> in.from �o ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> 7� <br /> ❑Other � <br /> GROUTING MATERIAL <br /> Grouting material � "c-y-����- 1 from � to � ft. yards �bags <br /> hom to ry, yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags � <br /> �, 1�� �. \\ � C'�r `�1� h <br /> -'� from to ft. yards bags <br /> / <br /> UNSEALED WELLS AND BORINGS <br /> _ O[her unsealed well or boring on property? ❑Yes No � <br /> i <br /> � ��"� � LICENSED OR REGISTERED.CONTRACTOR CERTIFICATION <br /> � � _ �..� : This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in�his report is - <br /> #-����� . ��� �. Vue to the best ot my knowledge. <br /> �`';�„� ., x �R„}t ,��L t_� � ( � f� �"! <br /> �'; . � 5„-r �' ���;� Contractor Business Name License or Reg tration No. <br /> .� , ':�` � � � LP-=i_ / � i�, f 5 <br /> Authorized Fj�presentative Signature a(e <br /> LOCAL COPY �"� Z�1�� , :���; �-,�_.., i. '� f , f } : � �~y <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-01 � <br /> � <br />