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Minnesota Welt and Boring <br /> WELL OF BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> Counly Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No. <br /> Mmnesota Stalutes.Chapter 1031 or W-senes No. <br /> 2.Yw...«.. � ILeave blank A not known� <br /> 78GS311C: <br /> Township Name Township No Range No Sechon No Fraction(sm �Ig� Oate Sealed Approximate Date Well <br /> or Bonng Constructed <br /> Urono 117 23 Z � � '�� <br /> Numencal Slreel Address or Fve Number and CAy of Well or Bonng Location t,�)� ` <br /> 2655 Shad R,(� Depih Before Seahng f J`-� fl Onginal Depih ��� fl. <br /> SFaw exacl locatan ol well or bonng Skelch map of well or�bonng StaGc Water Level Accurate <br /> in sec��on gnd wdh��X- locatron.showmg propert hne5. <br /> roads.and bu dings. ❑Approwmate <br /> N <br /> -�- - �- --- -�- �\ `� � �( <br /> i - <br /> � ingle AquAer ❑Mulhaqwfer . fl. '` below above land suAace <br /> i i i i � <br /> -I- -�_ _i_ _�_ � CASING TVPE <br /> W � E .t� <br /> � � � � <br /> -- -,- -r- -�- <br /> i i i i � � ���� Steel ❑Plashc ❑Tlle ❑Other <br /> mrle <br /> __ _�' _i_ _i_ � �;� / � / <br /> 7`� ��/ / '�) <br /> S Screen from—f---F-�O--- to �— ft. Open Hole irom to ft. <br /> ��^"k� - OBSTRUCTION/DEBRIS/FILL <br /> Obstruclion ❑Debns ❑Fill <br /> PROPERTY OWNER'S NAME <br /> Patrice Eller - i.�� L,P t=�1�iG � 7f i'"� <br /> Type of debns/obstructwn z --� L <br /> Ma�ling Address d ddterenl than property address indicaled above <br /> Obsirudwn/Debns/Fill removed7 es ❑No <br /> PUMP <br /> emoved ❑Not Present ❑ Other—,��`� �U�r <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diame�er Depih Set in oversize hole7 Annular space irntially grouted7 <br /> If not known.mdica�e esGmated IormaUon log from nearby well or bonng. <br /> i/ � <br /> � . � m.from �_to � fl ❑Ves �p ❑Yes ❑No ❑Unknown <br /> f, ,_ <br /> in.irom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown � <br /> in.irom to R. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �o Annular Space Exists <br /> Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> m.irom to ft. ❑PeAora�ed ❑Removed <br /> m.from to ft. ❑Perforated ❑Removed <br /> Type of peAorator <br /> ❑Other <br /> GROUTING MATERIAL <br /> Grouting ma�enal��16�J`C�L ^from �to �Sp� yards �bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> (rom to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes o <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The informa�ion contained in this report is <br /> M2 6 ,�g r, Irue to the best of my knowledge. <br /> p�`( Dcm S'iodola tzTell 1)rillin� Co., iP3c. 27172 <br /> Confractor Bus�ness Name �„ L�cense or RegisVa6on No. <br /> �,��. -� _ � -- 1 �� ��.`_ <br /> r <br /> A�e epre entativ�e " Dafer <br /> --�._i, . . ,. ,, �[/.. �.'x ..� <br /> �.,�,�,;;,,((°„��7"�Y � � � ` � - � Name ol Person Sea6ng Well oi Bonng <br /> HE�01434-01 <br />