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�. , . <br /> ' WELL OR BORING LOCATON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I '''}�'►'� � <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. - " ` " ' <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Lenva dank�I nd kriwn) <br /> Township Na e Township No. Range No. Section No. Fradion(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> ; Oroncs 117 23 10 3�-0018''' c <br /> . <br /> GPS Lati��de degrees minutes seconds <br /> LOCATION: Depth Before Sealing ��,,,�� R. Original Depth ft. <br /> Longitude degrees minutes seconds ppUIFER(S) STATiC WATER LEVEL <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location ingle Aquifer ❑Muldaqu'rfer <br /> 21/0 �.���.'t A�i VLV�ev SG3�3 ELUBORING �vleasured ❑Estimated <br /> ' Water Supply Well ❑Monit.Well � <br /> Show exact location of well or boring Sketch map of well or boring � <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other .�_ft. �below ❑above land surface <br /> N lines,roads,and buildings. CASiNG TYPE(S) <br /> - - - - - -- -i-- <br /> •--------'"""� Steel ❑Plastic ❑Tile ❑Other <br /> W --�- -'r- -i-- --i-- E WELLHEADCOMPLE710N <br /> , � \� <br /> T ti 11 <br /> 1 � cY� Outside: ❑Well House Inside: �iasement Offset <br /> -Y- -- - -;-- -i-- �� <br /> 1�� ❑Pitless Adapter/Unit ❑Well Pit <br /> --�- -�-- -�-- --i-- I <br /> 1 ❑Well Pft ❑Buried <br /> S <br /> ��"^�"-� _ ❑Buried <br /> � <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address it different than weil location address indicated above '�jE � �/ <br /> �� in.from �' to L1L_ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> in.f�om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknawn <br /> � WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � � <br /> Well owner's mailing address it ditterent than properry owners address indicated above Screen from�.�.�_t0��ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill �(1�10 Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑ No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Type <br /> '-' '1 � �— ❑ Removed Not Present ❑Other <br /> ; <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Iqs.,one bag of bentonite=SO lbs.) <br /> Grouting Material�f � `f�����from��to�.�Jft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEAUNG Other unsealed and unused well or boring on property? ❑ Yes No How many? <br /> i LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The intormation contained in this report is <br /> true to the best of my knowledge. <br /> Ik� Sto�vla Well Dcillir� Co,. Inc. I692 <br /> Contrac[or Business Name i License or Registration No. <br /> ..:,�� CJ f� <br /> i entatrv Sign re Date <br /> LOCALCOPY <br /> H 17�? � _� -� <br /> Name ol Person Sealing Well or Boring <br />