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Minnesota Well and Boring <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 2 9 0 4 2 ` <br /> �o��lY Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No <br /> Minnesota Statutes.Chapter 7031 or W-series No. <br /> �j: ;�{ (/\ ILeave b�ank,f no�knownl <br /> i <br /> Township Name Township No Range No. Section No. Fraction�sm. •Ig.) Date Sealed Approximate Date Well <br /> �,.,1 �, _.„, /' �� ,,,„, = `� or Boring Constructed � � Z3�y <br /> ,�_If/C.� C.. ��a �ia �ra ��'' . f ! <br /> Numerical Street Addres;or Fire Number and City of Well or Bonng Location .y ^7. � \ � <br /> " ' � I � � d � <br /> �� '..;/�_`,;V;� �'rv% � -� ✓Z.,n�,: Depih Before Sealing -�` fL Original Depth ' tt. <br /> Show exact location of well or boring Sketch map of well or bonng StaUc Water Level 1�Accurate <br /> �n sec�ion grid wi�h�'X��. loca�ion.showing prope�y lines. <br /> N roads,and build�ngs. ❑Approximate <br /> �i w� <br /> 1 I I I h / X � <br /> -� -�- -�- -� 1j"� � i- � �Single Aqui�er � q � �1 <br /> ❑Multia wfer ft. below above land surface <br /> i i i i - <br /> _i_ _�_ _i_ _i_ CASING TYPE <br /> W � � i i E �� <br /> i i i i <br /> _i_ _�_ _r_ _i_ <br /> � � i i � � f � �Steel ❑Piastic ❑Tile ❑Other <br /> 'o mile ��•^..` ... <br /> � � i i t V .S <br /> -� -�- -i- -i- � � � �,,.....'" 1� C= <br /> s <br /> S ' �.;.,. Screen from to ft. Open Hole from to ft. <br /> �-imile--►I 1 OBSTRUCTION/DEBRIS/FILL � <br /> PROPERTY OWNER'S NAME ❑Obstruction ❑Debris ❑Fill <br /> n <br /> � l.l 7 " � n ����; ��'.:t.� '" 1\.��,`^�-.�1...._ <br /> �\� � Type of debris/obsiruc[ion <br /> Mailing Address if ddferent than property address indicated above- <br /> Obstruction/Debris/Fill removed? ❑Yes ❑No <br /> PUMP <br /> ❑Removed �ot Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> tl not known,indicate estimated formation log irom nearby well or boring. �, ,.� <br /> � � in.from � to � � � fl. ❑Yes L�`Wo ❑Yes ❑No Y1 Unknown <br /> /p� <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to fL ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to fl. ❑Pertorated ❑Removed �, <br /> Type of perforaror <br /> ❑Other � <br /> GROUTING MATERIAL <br /> � ��, �.� <br /> Grouting matenal � ''�� �� from '�'� to � ' ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> , r r <br /> � i ( 1 <br /> � j f i' ..... y1..:. <br /> " � - from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? �Yes ❑No �`�-%�-'�� �. �: �!�^�, �'� ��--i(:. � � <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed m accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. _ <br /> �� s Y ��( f, �, � -� z� L� <br /> Contractor Bus�ess Name License or Registration No. <br /> ; ! � "S. <br /> �� N��`"---"\ \.�' �. ��� +� � f <br /> Authorized epresentative Signatuie Date <br /> LOCAL CCUPY �„+ �l .�< ;i',✓�� `.� v � . . (� �I ..l <br /> 2 g O 4,Z Name o/Person Sealing Well or Boring <br />� HE01434-01 <br />