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�• Minnesota Well and Bormg
<br />.',c�r; MINNESOTA DEPARTMENT OF HEALTH Sealin No. 3?0 6 7 14
<br /> Y� WELL OR BORING LOCATION 9 H �;�
<br />� co���v Name WELL AND BORING SEALING RECORD Mi��esota u�iq�e rvo. �
<br /> r�` Minnesota Statutes.Chapter 1031 or W-series No.
<br /> . � �Leave biank�f not know�i
<br />�� Date Sealed A roximate Date Well �
<br />�A� Township Name Township No. Range No. Section No. FracUon�sm. �Ig.� PP
<br /> ,���� or Boring Cons�ructed � � �
<br />�.,� �.� j 'ia �la �ra � —' '" .-- ~r' �
<br /> . l
<br />�. �� Numerical Street Address or Fire Number and City of Well or 8oring LocaGon � � ' ".��`
<br /> t y \
<br /> .�r �.,. 7 r Depth Before Seating �� / „ ft. Original Depth -�i. fL �
<br />�- � � �� -_ -' :°�
<br />�-. Show exaci location of well or boring - � ketch map ot well or boring Static Water Level �Accurate ��
<br />�,i,`; in section grid with��X��. V bca6on,showing property Imes. ��
<br />`�> roads.and buildings. ❑Approximate
<br />'E N
<br /> �• v� �., u� v
<br /> '_ _ '_ _' _ _' ))) ,y
<br />��� -� � � � � �— ingle Aquifer ❑Multiaquifer �ft. --Yl� below above land surface �
<br /> i i i i �
<br />��_ _i_ _�_ _i_ _i_ _, CASING TYPE ;,�
<br /> W i i i i E
<br />� � '�
<br /> � � � � �i
<br /> _�_ _y_ _r_ _�_ '�.
<br />� i i i i • '� � teel ❑Plastic ❑Tile ❑Other �
<br /> :t mile �
<br />�,:. _�_ _!_ _� _ _�_
<br />�4 � � I i �
<br /> r'
<br />�,: � � , Screen from to ft. Open Hole from �o ft
<br /> ' �--l miie—►I �. j�,'�I� OBSTRUCTION/DEBRIS/FILL
<br /> x ��Q�
<br />��e� PROPERTY OWNER'S NAME ��'�1�'•�°'� �Debris ❑Fill g
<br /> 2 w
<br /> a
<br />���. � r� ��.� " � �' Typeofdebris/obstrucGon � ��-� �� �,� �� �� i : � i; ��` ���.� � �
<br /> �*'� Mailing Address if different ihan propeAy address mdicated above. � y+
<br />,c'- Obstruction/Debris/Fill removed? Ves ❑No �„�
<br />"�`�.. ,�"`j�l WL,Q. PUMP
<br />�-��:. . � ��
<br />��
<br />.,�� ❑Removed ot Present ❑ Other
<br /> CASING �
<br /> HARDNESS OF
<br /> t GEOLOGICAL MATEHIAL COLOR FORMATION FROM TO
<br /> .�'�*..'„ Diameter Depth Set in oversrze hole? Annular space initially grouted?
<br /> a�1'a� If nol known,indicate estimated formation log from nearby well or bormg. '�
<br /> � S
<br /> �_in.from �,.' to �� ft. ❑Yes �lo ❑Yes ❑No �Unknown ��.
<br /> in.(rom to ft ❑Yes ❑No ❑Yes ❑No ❑Unknown _,�
<br /> "'^ �
<br /> � In.irom to fL ❑Yes ❑No ❑Yes ❑No ❑Unknown '�
<br /> T� �
<br /> �. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND 80RE HOLE:
<br /> a:
<br />�,.. �No Annular Space Exists
<br />�-. Annular space grouted with iremie pipe
<br />�<'„ ❑Casing Perforation/Removal ��
<br /> i "
<br /> �� in.from to ft. ❑Perforated ❑Removed .�
<br /> � '�
<br /> F.„
<br /> �: i.'.
<br /> in.from to ft. ❑Perforated ❑Removed .�,�:
<br />� �
<br />� Type of perforator i:;.
<br />� `�
<br />�� %��
<br /> ' ❑Other ��
<br /> �*'� GROUTING MATERIAL
<br /> �
<br /> � ,
<br /> + ��
<br /> T ;�
<br /> ,� Grouting material i��.. ` j„��� I/� .�_1'�' from �.,�to �_Jt. yards �bags
<br />� � �
<br />�� �
<br /> �� from to ft. yards bags
<br /> �� REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
<br /> irom to ft. yards bags �
<br /> ' +' �" _.
<br /> < �,���� �� i . �,��
<br /> ) - . '��
<br /> r� -
<br /> from to fl. yards bags
<br /> `�,� �.t�.,y�..�g,��} � , ��l.. i,y� �� , `.. �� UNSEALED WELIS AND BORINGS ';:
<br /> � IS
<br />��,� � � Other unsealed welt or boring on property? ❑Yes , o
<br /> t ; �� � j
<br /> / �,,t J 1 �s��„� � y f� i �, .. IICENSED OR REGISTERED CONTRACTOR CERTIFICATION
<br />��� � This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is ��
<br /> / �� � �,. ��'l r � � irue to the best of my knowledge. �
<br /> �._.' V ... �
<br /> r
<br /> i f � � �
<br /> 1��� v i ! � �' �
<br />� �� Contractor Business Name License�Registration No. �
<br /> � � a 1 � '(
<br /> �, - _ r9 `� `,,.�. _ .:-r
<br /> ,�:��,�,�,,�_ ,�
<br /> �`� Authorized Rg�resentative Signature "�� Date
<br />��' � . , , , :../
<br /> � LOCAL COPY �„� � ��. �- t'' � i . - vt ` ! �
<br />�: Name ol Person Sealing Well or Boiing
<br />��, HE-07434-01 .
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