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Mmnesota Well and Boring 1217 5 3 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> �o���Y Name ,I WELL AND BORING SEALING RECORD M���esota u��q�e No <br /> y�, �t^ Mrnneso�a Sta�utes. Chaptei 103/ or W-series No. <br /> � � I�eave blank if not knc�wn) <br /> Tow iship Name Township No Range No Sec�ion No Fradion�sm. �Ig) Date Sealod Approximate Da�e Well <br /> ���D ; / '� /!�j / or Bonng Constructed / �j�O � <br /> 'ra '�a 'i.i � / C) / <br /> Numencal Street Address or Fre Number and City of Well or Bor�ng Location 1 ) <br /> CJ`C' �'� � <br /> � �-��-��� � ��� „���� ;_� �U� Depth Before Sealing � � "ri. Original Depih � �� � ft- <br /> Show exac�location ol well or boring � Sketch map of well or bonng Static Water Level Q�Accura�e <br /> in se tion grid with��X� � location.showing pwperty lines. <br /> ��..O�Q N � % roads.and bwldings ❑Approxima�e <br /> �V <br /> 1 <br /> -- - i i i_ r'fL.f <br /> �� ��� �� �ngle Aquder ❑Mult�aqwfer � 1 fl. below above land surface . <br /> i i i i � <br /> _i_ _�_ _a.- -i_ CASING TYPE <br /> W i i i E *� <br /> � � � � � � IY�V T 7 � . . <br /> -r -i- -r- -I- � <br /> i i � �Steel ❑Plastic ❑Tile ❑Other <br /> mile <br /> __ _ I I I_ � �t)t� <br /> I I I <br /> Screen from to fL Open Hole�rom to iL . <br /> S L, u _ {�� r <br /> �--�mi�e---� - ' " OBSTRUCTION/DEBRIS/FILL <br /> ��i,: t_ �y <br /> tn,Obstruction ❑Debns ❑Fdl <br /> PROPERTY OWNER'S NAME / <br /> , , ' t. <br /> r � -' � C_:I`'- � 1 j� . I i Y �`, <br /> Type of debns/obsiruclion .- ���� <br /> Maihng Address d drfferen��han property address indica�ed above <br /> Obsiruction/Debris/Fill removed7 �Yes ❑No <br /> - �=:. �/ �� PUMP <br /> I�Wemoved ❑Not Present ❑ Other <br /> CASING <br /> GEOIOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depih Set in oversize hole? Annular space initiaily grouted? <br /> It not known,indicate estimated formaLon log from nearby well or boring. � � ��,+ <br /> / �� ,a/� �,/ <br /> }� �,V�\ in.from to ft ❑Yes L�1+lVo ❑Yes ❑No QUnknown <br /> /"a <br /> in.from to it. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to fi. ❑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 /> � in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Pertorated ❑Removed <br />�:; <br />-��'" Type ot perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> � <br /> +1 r ; 1. ,!I ,� <br /> Grouting material �������- '��' �`-U` � ` � from ' 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 /> � <br /> �, �: <br /> _. �i�..�_ , �, � � t <br /> trom �o ft. yards bags : <br /> s <br /> �/,. � "�'�� � UNSEALED WELLS AND BORINGS <br /> � '� 4 <br /> � = (_� � �-�'` I' l <br /> Other unsealed weli or bonng on property? ❑Yes �No <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 /> irue ro the best of my knowledge. <br /> �Y , I I c�, � �� G� <br /> Contractor Business Name License or Registration No. <br /> E; <br /> � �; � ? - 96 <br /> -,-�i�— : <br /> Authorized Repres�ntative Signatwe Date <br /> LOCAL COPY H , � �.'^� �,,/ �F K ���� <br /> 1217 5 3 Name ol Person Sealing Well oi Boring <br /> HE-01434-01 . <br />