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�� :�� G�" Minnesota Well 8nd Boring ^� �^ � �'' � WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H �J 1! �" �o��Y N,me WELL AND BORING SEALING RECORD M��esota un�q�e No L �� � �� Minnesota Statutes.Chapter 103/ or W-series No. iw.: fLeave blank il�ot knownl � �"., Township Name Township No. Range No. Secti hon(sm. �Ig.) Date Sealed t ` Approximate Date Well 'p � �� f9 1 4�fa�ra �y � ` ^} � Ca � or Boring Construc�ed L..7 � f � " Numencal Street Address or Fire Number and City of Well or Bonng Location ,1 �� 332k Navarre Lm�e Orora l+�i' 55391 Depih Before Sealing � ft. Original Depth � ` ft. �x ;� Show exac�location of well or boring Sketch map of well or boring Static Water Level Accurate '��' ��= in section grid with��X�. location. owi?Tng pr erty lines. �'� �-' N roads.an buildings. ❑Approximate ,�� '"a, � � � � ja � -,- -;- -,-- -,- �� -�� ;�, Single Aquifer ❑Multiaquifer �ft. �— below above land surface �F�� i i i i � f � �" . -'- -�- -i- -�- CASING TYPE �% W � � � E _, ; � \� ' �� i i i i ` _i_ _�_ _r_ _�_ � ,g�' � � � � '�mile F �� Steel ❑Plastic ❑Tile ❑Other �y ,: '"� -�- -�- -�- -�- � � -� �� .�-�.. i i i i .� �+'� � Screen from� to � tt Open Hole from to ft s�-�".. �--i Si/e—�I � OBSTRUCTION/DEBHIS/PILL � � _� ❑Obstruction ❑Debris ❑Fill y� - PROPERTY OWNER'S NAME � r x c-y ]� .7�c � ... p:..j:�,J G L�@ l v��v �� O 1JSt f N��y U�� ':.. Type of debris/obsiruction �� `,�� Mailing Address it difterent than property address indicated above. " Obs[ruction/Debris/Fill removed7 Yes ❑No PUMP � � � ,,s"; ❑Removed Not Present ❑ Other � �,a`: ' CASING �k GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION �� Diameter Depih Set in oversize hole? Annular space ini[ially grouted? �? If not known,indicate es�ima�ed formahon log from nearby well or boring. ` ' �y �in.from � to �� ft. ❑Yes y�No ❑Yes ❑No ❑Unknown _ a= � � , ��z; ; in.from �o ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown ' ±k: J. P<`- �__�;_ in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: - ''�.-�'--*r`. No Annular Space Exisis ��'�a:' � ❑Annular space grouted with tremie pipe � ��, .. �. ❑Casing Pertoration/Removal �" .. ��- .. � in.from to fL ❑Perforated ❑Removed � ',� ,�t. #_ ,�� in.from to fl. ❑Pertorated ❑Removed 3�,� �:. � �' �^ Type of perforator .... y�� tt t�. .� �z: ❑o�ne� GROUTING MATERIAL Grouting material �� C.��V\1 �rom � to ��ft. yards �bags from to ft. yards bags REMARKS,SOURCE OF DATA,DIPFICULTIES IN SEALING �� from to fl. yards bags G�rcwtte.c�2" �e.11 84 ' d�ep 2 �� t from to ft yards bags 4 liR7 /,.iCllCVil1T� UNSEALED WELLS AND BORINGS 2 � �rf � � �t ��jy, � Other unsealed well or boring on property7 ❑Yes No LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minneso�a Rules.Chapter 4725.The information contained in this report is - true to the best of my knowledge. - � y ��. D� stc�clela GtF+1I�i11i.�C�o.TInr. �7172 �'� - ;� Contracror Business Nam License or Registration No. , N >.. .•. ZM.�a.- ',-�:; w ' - _ « ._.__ �y y,. ' _ ; �- - r� . - , epresentative SignaTure Date - �oc�coPv H �8 7�� ?� I,e�ke � Name ol Person Sealing Well or Boring �E-01434-01 ;�: