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� <br /> Minnesota Well and Boring 3 9 8 8 0 y <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H �- <br /> �o���Y Name WELL AND BORING SEALING RECORD M���esota u��q�e No '' <br /> Minnesola Siatutes.Chapter 1031 or W-series No. � <br /> �, �-� (Leave blank if noi knowni <br /> Township Name � Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Welf � <br /> �}` �'} or Boring ConsVuc�ed <br /> r::;;{)�'�„r / ✓b h',a�s.r'rgf�c�',a � y� (/ j � � <br /> Numerical Sireet Address or Fire Number and City o(Well or Bonng Location <br /> i��.. r:�� � <br /> /�'� �� _ � Depth Before Sealing :� u (t. Original Depth —��,' ft. � <br /> - .. i .r�.., � <br /> Show exact location of well or bori Skelch map of well or boring Stafic Water Level [�Accurate <br /> in section grid with��X��. location.showing property lines, <br /> roads.and buildings. ❑Approximate <br /> N <br /> � �� <br /> _i i i i_ L'J .�"`�� <br /> � -�- -�- -i 7` <br /> Single Aquifer ❑Multiaquifer �fl. X below above land surface <br /> i i i i <br /> _i_ _�_ _i_ _i_ CASING TVPE <br /> W i i i i E � <br /> i i i � � } � i � <br /> _i_ _�_ _r_ _�_ 'f <br /> � � � � �amiie Sleel ❑Plastic ❑Tile ❑Other -� <br /> _i i i i_ � �� /� <br /> i_ _ i_ _i _ _i <br /> Screen from ;,�7--�— to ��' tt. Open Hole from to ft. <br /> ��S'�e �I OBSTRUCTION/DEBRIS/FILL <br /> �Obstruction ❑Debris ❑Fill <br /> PROPERTV OWNER'S NAME <br /> 1 � ����; <br /> .�,�:''_ '�. :r ,, •�,��� , � ��.t..` �{ ��-"-�'dL' <br /> Type of debris/obstruction <br /> Mailing Address rf differeM th�['eAy address in � ted above. <br /> Obstruction/Debris/Fill removed? Yes ❑No <br /> PUMP <br /> . _ a <br /> �Removed ❑Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION � <br /> Diameter Depth Set in oversize hole7 Annular space initially grouted7 <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> �in.from to �— ft. ❑Yes �No ❑Yes ❑No ❑Unknown t, <br /> 1. <br /> in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> _�,- {--. in.from to k. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> - €:'.�- (J r,.' <br /> . . METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �lo Annular Space Exists <br /> ❑Annular space grouted with�remie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑Periora�ed ❑Removed <br /> in.from to fl. ❑Perforated ❑Removed <br /> Type of perforator <br /> � <br /> '1 � ��J3 ❑Other ,� <br /> GROUTING MATERIAL <br /> Y , <br /> r <br /> Grouting material � ' ' from to r��_fl. yards f bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE A,DIFFIC@LTIES IN SEAU � <br /> �. <br /> 1' ��r-(`UJ from to ft. yards bags <br /> L�U V � �� ��:: <br /> t � <br /> from to fl. yards bags <br /> "�`��� UNSEALED WELLS AND BORINGS � <br /> °"� ,��'�,,c '�-,: <br /> 'F` - Other unsealed well or boring on property? ❑Yes �lo <br /> '��� .� ' - � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> : �;K ��,*��., <br /> �''---� � ��w? This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> 2„ ��. ���i �, _ � irue to the bes�of my knowledge. <br /> -a .. s ' � ' � . <br /> �� � �� <br /> ..: '�`,rs�. . _; . <br /> N . <br /> ,a� ,.�� 4: �� .: '�a �1.'S•'��: ��� l/ ..1 (.�.. y„/ J �/ } / �! <br /> - - t `r�.'-. �:,<� .. .*�/`�.. ./'! ~ J .1 � p � <br /> �s . <br /> ' Co ractor Business Name - License or Registration No. � <br /> . x_:, .. ._� ,. 2�` �,. `� -�,� .,c-_._? .... -+�....._,✓ ,. - n <br /> x� _ . _ j �7 <br /> - i ! f v % �" � <br /> Authorized Repiesentahve Signature Date � <br /> ir,, <br /> LGCAL COPY I„I : � - � <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-01 ��� <br />