WELL SEALING 09.05.1996WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH alp ms m�Well and Boring H 108788
Camty Herne
WELL AND BORING SEAUNG RECORD s"""'No.
No.
hfut�r Chap�r ro3! orw- ramie e
Toameitip Nerm Tcwm* No. Range No. Steriat No. Fmobn (inn, •► ig.) Dote Sealed Date Wap or Soft Construded
Jit pg 30 IRV, / &a Ad
Numerical Street Add. or Fire Nwriber and Coy of Wap or Boring tin ,Q
Fje'� gcaq� R OraBirmt OeP4h �u if
show east boavan at wall orboring SfearnapalwaVorbming AOUIFE " STATIC WATER LEVEL
In seaftn grid with W. wwftn showing Proplaw S shtgts Aguilar ❑ M iltimquifer
Hasa
N roads,artdbWidirtge. WIEUMOR00 E Measured [03
water aq* Well ❑ Math. Weft
❑ Ern. Bore lima ❑ O9rer 59 -it :r below ❑ abaft rand emfase
Wt: i C TYPSM
■ steal ❑ PlaWo p'Tila ❑ olhar
u rare
(l
CAB=
/_V- � �tx . , u set in a+ersim hub? Amer spine h 3292 grouted?
�, �:� m trap d �m tt ❑ Yes
No ❑Yes ❑ No ❑ umamwm
PR11a01lYNZFA14± in. from tofL ❑ Yes p No ❑ Yes ❑ NO ❑ UrAu—
property a aad6ngaddroee oditferorrtd,en Beat beedon eddraw stale. In. from to ft. ❑ Yes ❑ No ❑ Yea ❑ No p Untawwo
SCrISENPOLHOLEE �r
screen frau f� -r m 4ge/ & Open Hole tam to fL
WELLOWNEII'SNAME ❑ Obstruction ❑ Debris ❑ Fig a NoObn
Welarms outsftaddreseffWarer Vmp""cmWomdftmk4cmbdabvm Typtof0bWu0loWDebftM
rernovedT ❑ Yea ❑ No
PUMP
To.
tiEUMCALNATER" COLOA OFFROM TD ❑ Ramafed 3 NotPresent ❑ OMrer
n rat wawn tr�Oats aeNnraud fommtian ic0 from naarbyrats erbairg METHM USEDTO SEAL AN A M SPACE SETWEEN fl CAWMS, OR CASMIO AND BORE HOLE:
! No Am Ww Space Exft
AsAll R— ❑ Armorer space grouted with berme pipe
L/f 60 ❑ own PerfaaBoNRe w
I:%E S rC%� l to from m fL ❑ PaAorated ❑ Rema ed
tn. from m ix ❑ Perforated ❑ Removed
Type of perfaramr
0 `12 ❑ Other
�� � t�� 6ROU71NG MA
C-0 Slowug 6 m S yards 3 bags
tram toft rfa lw
vm
from to ft yards bags
from to R. yards begs
REMARKS, SOURCE OF DATA, WFICLUMES 81 SEALING UNSEALED WELLS AND EOWNS
%' c, �I a 4 other unsealed wall or boring on property? ❑ Yes ONO
UCUfSED OR R AWFSVM COMIACM CEMMROXIM
ri'�J� �/�.+J r� /�C��::� Ttdsweh or twdng lues seared In aooardanoe aaE, NQnnesota iTrdeaChap4er 472b. The i�rrn�on conmined in the report Is
hotafhe bestof mytswwladae.
( c�Ga6Y T� �y Fiearr, A DM - STA79 4MZ.L -*+At A;X)-d 2 -,Me '7' aolt�
FtL .f r : S'3 ? t'�2/t t tdcanse arRegietraXarr No
ujkT,c2 L.Et1EL !iV f�.dSOt9�
Fm -
NN. DEPT OF HEALTH COPY H 108788
A r s W age p
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