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� .. . <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring F„' <br /> Counry Name <br /> WELL AND BORING SEALING RECORD Minnle ota Unique Well No. <br /> �i��� Minnesota Statutes,Chapter f031 or W-series No. <br /> 0.e.�o m�,x n no�wqw�l <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constnicted <br /> oro�o 1�� z � �z-cx��.o ,. o� <br /> GPS La►itude degrees minutes seconds L � <br /> LOCATION: Depth Before Sealing � ft. Original Depth k. <br /> Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> s�C� ��,p�' �� ��+��� WELUBORING �Measured ❑Estlmated <br /> '�'� s� '� �Water Supp�y Well ❑Monit.Well � <br /> Show exact location of well or boring Sketch map of well or boring <br /> in secGon grid with"X" location,showing property ❑Env.Bore Hole ❑Other �ft. �below ❑above land surtace <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> - - - - - -- - -' '.i <br /> C'���- Steel ❑Plastic ❑Tile ❑Other <br /> O <br /> W --�- -;-- -;-- --,— E ,�� WELLHEAD COMPLETION <br /> � �y �'y Outside: ❑Well House Inside: ❑Basement Offset <br /> _Y_ _i__ '1__ _j__ ? <br /> I r�w1 <br /> 1�� �itless Adapter/Unit ❑Well Pit <br /> --;- -i-- -�-- -�-- � <br /> � ❑well Pit ❑Buried <br /> S � <br /> �—�'"��" ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diame er � Depth � Set in oversize hole? Annular space initialty grou[ed? <br /> Property owner's mailing add�ess"rf di8erent than well location address indicated above /� <br /> � in.f�Om� t0�..�ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> in.f�Om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑ves ❑No ❑ves ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> + r <br /> Well owner's mailirg address if diBerent ttian property owners address indicated above Scfeen f�om /�0 to �`� ft. Open Hole ffom t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Y@S ❑ NO Describe <br /> FORMATION <br /> It not knpwn,indicate estimated fortnation log from nearby well or boring PUMP <br /> �. Type <br /> � ' ���~r ❑ Removed Not Present ❑Other <br /> METHOD USED TO SEA ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � �No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Remrnal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> i <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=501bs.) <br /> < ' ,,• ` / <br /> Grouting Material�/���'from��to L.SL�L ft. yards �_ bags <br /> � � � <br /> from to ft. yards � bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The infortnation contained in ihis report is <br /> true to the best of my knowledge. <br /> Dan 5tod41a We12 Dcillin;; �o,. Tnc, 169I <br /> Contractor Business Name License or Regisha6on No. <br /> , r .. <br /> s� I_�' ��'' .,Eo <br /> A o d �'e �gnatu Date <br /> H 251768 � � ,� .,� � : � ,r.��,._ <br /> LOCAL COPY '. ` <br /> Name ol Person Sealing Well or Boring <br />