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Minnesota Well and Boring WELL OR BORiNG LOCA7iON MINNESOTA DEPARTMENT OF HEALTH Sealing No. H �o��Y Name� WELL AND BORING SEALING RECORD^^��eso�a u��Q�e No , I��p�� Mmnesota Statutes.Chap�er 103/ or W-senes No. ;` ILeave blank il noi knownl Township Name Township No Range No Section No Fraction�sm. •Ig) Da�e Sealed Approxima�e Date Well �O�> 1,�_l L� l,J �i�t,f(;�� or Bonng Cons�ruc�ed �' la Numencal Street Address or Rre Number and Gty ol Well or Bormg Location 1(`'� � / ' � %!% ��K �3.�i� �� l. :�7 ih�„ Depth Bebre Sealing ""'`U ft. Ongmal Depth �� ft. Show exact locatan of well or bonng Sketch map of well or¢onng Static Water Level Accurale m secuon gnd wdh��X�� IocaUon.show�ng prop�rly�ines. � � io�d�ap�l I�LJdings ❑Approximate N i _�_ /t �( � / � � � { � S�ngle Aqulfer ❑Multiaqwfer �v fl. '` below above land suAace � i � i t _i- -�- -�- � CASING TYPE W E � � � � -r -�- -r- -r i i i i � leel ❑Plashc ❑Tde ❑Other mi�e -�- -i- -�- -i- � ..1i... - � �U� / � 7 //`� S Screen from � lo ��G` ft. Open Hole from to ft. �""'k� .�L�.I � vL � OBSTRUCTION/DEBRIS/FILL Obsiruc�ion ❑Debris ❑Fill PROPERTV OWNEH'S NAME D1CJ� & ��y Hc�l�(:�I J� /� Type of debns/obslrucUon �-�`,-A-.J��—��.T/"�f �` G.=tr1T` MaJ�ng Address d ddterent Ihan propeAy address�ndicated above. �� Obsiruction/Debns/Fill removed7 Yes ❑No �2�3�) Halca� Bricige P�UMP �Itha�ett.�, ceorgia 5�l�—p�11�3l� 1tf'�—q��—�i g� 3G'1.02 Removed ❑Not Present ❑ Other CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depth Set in oversrze hole? Annula�space mitially grouted? II not known.�ndicate es�imated formation log irom nearby well or bonng. 4- �/� /`, / in.from �to�(1� fL ❑Yes �lo ❑Yes ❑No ❑Unknown in.trom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �!o Annular Space Exisis ❑Annular space grouted with Iremie pipe ❑Casing Perforation/Removal m.from to tt. ❑Perforated ❑Removed m.irom lo R. ❑Perforated ❑Removed Type of perforator ❑Other GROUTING MATERIAL ...., �` � Grouting materialA,��,1 ��j7�js� (rom y,�to ��_ft. yards �bags ,r— from to ft. yards bags REMARKS,SOURCE OF DATA,DIfFICULTIES IN SEALING from to fl. yards bags from lo ft. yards bags UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑Yes o LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The iMorma6on contained m this report is �rue to ihe best of my knowledge. Dii�; ti'i+ODtsLA i�i� UR11..LTNG CG., IH�. �11 i� Conhacfor Business Name License or Registrahon No. i � "` -''` -��'.��-.T�� .-� f I - !'i -,�/ h e � pFesentat�e Signatura Date --i ` ..�� _ . H � � �' ' '� l , � �, , � �,�'„�j„�;�"Y( •• � Name ol Person Seahng Well or Bonng HE-01434-01