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Minnesota Well and Boring <br /> '�� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 5 6 9 8� <br /> co���Y r�ame WELL AND BORING SEALING RECORD Mm�esoca uniq�e rvo. <br /> + — i�T1I1. Minnesota Sta�utes.Chapter 1031 or W-series No. <br /> ILeave blank il not knownl <br /> Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br /> ^� ��� t�� or Boring Consiruded <br /> 1� f �� LSV ��ti�[9� �ra �� <br /> Numerica treet Address or Fire Number and City o(Well or Boring Location � j <br /> 5J7 �C1�.tC �. C�rC.�{1 J5356 Depth 8efore Sealing /�� ft. Original Depth j�� ft. <br /> Show exact location of well or boring Sketch map ot well or boring S[atic Water Level ccurate <br /> in sedion grid with'X". ;. /'� location.showing property lines. <br /> �J ��i'.,., roads,and buildings. ❑Approximate <br /> :� ��� <br /> N <br /> _� i i �_ __.'.� � # � � <br /> i_ ___ _i_ _i �3i:,, � <br /> �,ry '��� q � =- ingle Aqwfer ❑Multiaquifer �ft. � below above land surface <br /> i � i i � � � <br /> _i_ _�_ _i_ _i_ ; CASING TYPE <br /> W i i i i E � � <br /> i i i i \ � �� <br /> -i_ _�_ _r_ _i- ..\}. •• <br /> i i i i �e ��e _s �, teel ❑Plastic ❑Tile ❑Other <br /> i i i i � . <br /> -i - i- -�- -i � � � / <br /> S � � � Screen from � to � ft. Open Hole from to ft. <br /> �--1 mile—� 1.,;�'� OBSTRUCTION/DEBRIS/FILL <br /> ❑Obsiruction ❑Debris ❑Fill <br /> . PROPERTY OWNER'S NAME <br /> LA.R.; c- t�,t�.it.... ���� <br /> Type of debris/obstruction <br />. �� Mailing Address d diflerent than property address indicated above. <br /> Obstruction/Debris/Fill removed? ❑Yes ❑No <br /> j PUMP <br /> { � �� _ '�+/� ° `__ � ! <br /> 4 ❑Removed ot Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diame�er Depih Set in oversize hole? Annular space initially grouted? <br /> It not known,indicate estimated formation log from nearby well or boring. ,� , <br /> }��,i .L j��'� [ (t�-.,' �in.from �to L.SdQ fl. ❑Yes J�VJo ❑Yes ❑No ❑Unknown <br /> tl � v t t; <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.(rom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> OCNo Annular Space Exists <br /> �� <br /> ❑Annular space grouted with tremie pipe <br /> � ❑Casing PeAora�ion/Removal <br /> � - ' in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type ot perforator <br /> ❑Other <br /> � GROUTING MATERIAL <br /> w f <br /> Grou�ing material�/'��.'��� �'��`�� irom �_to �ft. yards �_bags <br /> from �o ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to fl. yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes o <br /> LICENSED OR REGISTERED CONTHACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained m this report is <br /> Vue to the best of my knowledge. <br /> Lbn Stcx;r;l.a hlell Dri11�.x�g Inc. G'i 1 i� <br /> Contractor Business Name , �� :- �' License or Registration No. <br /> ,�'' : ` �� <br /> . � <br /> __ , . , � . <br /> � . : , <br /> r �` �< „e�- . <br /> o epresentative Signature Date <br /> � � � <br /> LOCAL COPY H �,J��V� �� ' r � �'�� � �' � _� � I_ <br /> Name ol Person Sealing Well or Boring <br /> �� HE-Ota34-01 <br />