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wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring County Name WELL AND BORING SEALING RECORD Sealing No. H 113 5 5 4 Minnesota Unique No. �tEr C1Tic'I.:1 T! Minnesota Statutes,Chapter f031 or W-series No. - (Leave blank if not known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �li'r�Ilrf � �. E . �.,l4 `)__� �`vf�.� '!56 � '.��'.% f :�:.j� C(T(QF Numerical Street Address or Fire Number and City of Well or Boring Location a_ n� .r•�il P N Q I'��) 5�l lJ I E` �12' - t.�T��z i'1!'.+ Depth Before Sealing g' p \✓/ �`� ft. Ori mal De th � V Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL in section grid with"X°. location, showing property �Single Aquifer ❑ Multiaquifer " . lines,roads,and buildings. "'� . - N WELUBORING 4`�Measured ❑ Estimated � � � �[�Water Supply Well ❑Monit.Well . .q 1(`^�' - - -i-- -;-- --;-- � ' p �1 R �- ; � '`❑ Env.Bore Hole ❑Other '� � ft. �below�6Jve la�d sJrtace i � � � i i � • —�- -�-- --�-- --�-- yy E �/- :� �� CASING TYPE(S) i � i � � � i . � i i � � ' ...__..._._._ ..._. _ � �-- '�-' --�-- i �Steel ❑ Plastic ❑Tile ❑Other �1:_'t?'�, ��`�- _ 1 Yo mile 1 �. I- --�-- -�-�-c, � � - � CASING ""��"'"��'-"'��" Diameter Oepth Set in oversize hole? Annualar space initially grouted? LL"" S p�t mi�e� . . - 't f`in.from to ��i. ft. ❑ Yes �No ❑ Yes ❑No ❑ Unknown I PR F� iY O ER'S NF.�IvJE in.from to ft. ❑ Yes ❑ No ❑Yes ❑No ❑ Unknown �.°�.��`�.,a , �,�i�x Properry owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑Yes �No ❑ Unknown L I f�U�iH L,, .I�_'I�IV SCREEN/OPEN HOLE I -4 i?t� ��f.n s �'t3 i t��, Il c�a�� ; : '•.� Screen from to R. Open Hole from to ft. ';":"c.�i1�; . �id '.}��._;+� - OBSTRUCTIO WDEBRIS/FILL WELL OWNEF'S NAME Obstruction ❑ Debris ❑ Fill ❑ No Obstruction e�': .i_i Well owner's mailing address if di8erent than property owners address indicated above. Type of Obstruction/Debris/Fill ` i . i 1 �'.�- +� t �� % >i a�� i�� Obstruction/Debris/Fill removed? ❑"�'Yes ❑ No PUMP TyPe i��' .�i1�'it`:�: ii.�.<. j;!.111<�. ,_ tll�.' "� GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Q�Removed ❑ Not Present ❑ Other FORMATION 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: ❑ No Annular Space Exits ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) Grouting Material 'U{' t� i:F+:$ from to ifi . yards bags Er=., �_t t.;� ; ,i� _; �:i . _.: ;� from to ft. yards bags from to ft. yards bags from to ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTiES IN SEALING UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑ Yes Q,No ��.l�,_L t�.` -� _ %:i.�.��i�i L f'I' t��C'._i�r-_� ;"�c;j'�„�'1 LICENSED OR REGISTERED CONTRACTOR CERTIFICATION r .i S 1�tt O f� �A S 0lAE��!�'.. t� �..l��t�f': �� - This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is ��,d: zs;,��n'� �'q�j t,�Xl�,;;:'- . , . true to the best ot my knowledge. x f . - Contrac(or uSiness�7ame' ` 'Cicense oi Registration No. �'� % !� F�, � i �it i-:_�_; �;.�.I r�r,k�:: : r�' ' ` � _ . � � � ` � Authonzed Representative Signature % Date t`�F1�` . ..— � i f --..�<— f,�'_l`t(.�'t_3 � >. s i. � r� ;,p. � -, � r� � � �q Name ol Person Sealing Wel!or Boring I.00AL COPY H z� � G' HE-01434-02 10/95R