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WELL OR BORING�OCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota I q, `� `� � S `�' � <br /> Sealing No����� L,� ' J �r !` <br /> ` County Name WELL AND BORING SEALING RECORD Minnesota nique Well No. �— <br /> Minnesota Statutes,Cha ter 1031 or W-series No <br /> T p �Leava biank!noi k�owi <br /> � <br /> Township Nam`e Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Wel �n o strtic ed � <br /> 1 '�` �'�`' 'r � 1.� <br /> � GPS LOCATION-decimal degrees(to four decimal places) � c� � <br /> :� � Depth Before Sealing_�_�___ ft. Original Dep[h_ ___________ ft. � <br /> Latitude__ _ _ Longitude <br /> �UIFER(S) STATIC WATER LEVEL <br /> Numerical Sireet Address or Fire Number and City of Well or Boring Location , ingle Aquifer �_'��Multiaquiter V <br /> c+f WELUBORING Measured � �Estimated Date Measured�� �! __ <br /> `�� ?�i� :I.la�.!� Q� �� �CnC�C) �- ater-Supply Well ��Monit.Well j — ��- <br /> Show exact location of well or boring Sketch map ot well or boring - - �� below �' � <br /> in section grid wdh"X:' location,showing property �Env.Bore Hole ', :Other__ _ �.� ..__ft. � above land surface <br /> N lines..roads,and buildings. CASINGTYPE(S) <br /> :. -'--- - --` - -'-- � <br /> ;; j j j Steel ���._'��Plastic � Tile !,�Other <br /> � --'-----�-- ---`- --`-- WELLHEAD COMPLETION <br /> � ,�, ; : �, : ET . <br /> ; ; ; _ �____;__ Outside: 'J�Well House . I,At Grade Inside� '�Basement Offset ,� <br /> ���Mi1e ❑Pitless Adapter/Unit - .Buried � I Well Pit <br /> --,--- --.-- --.- > - 1 <br /> Buried <br /> ' S ' �:_'-WeII Pit <br /> �,]Other <br /> �-1 Mile--� _.Other__. __ _ __,_.__ <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) � <br /> Ca ' Diameter � Depth � Set in oversize hole? Annular space initially grouted? . <br /> Property owner's mailing address it ditterent than ell location address indicated above �r�in.Gom� to_��ft. !_j Yes �No [_Yes ❑No i J Unknown <br /> —b`— <br /> 125 ���n �t ���`f ��� ��� in from to fL � �Yes I �No L Yes ❑No _�Unknown <br /> "'innea�lis, '��`� 55414 <br /> in.from ta ft. �Yes �. '�No '_�Yes ❑No L��Unknown <br /> WELL OWNERS NAME,'COMPANY NAME SCREEWOPEN HOLE <br /> Well owner's mailing address it different than property owners atldress indicated above SCreen irom_� ! _to_���_ft. Open Hole from ____, ,.,_to ft. �� <br /> OBSTRUCTIONS <br /> � Rods/Drop Plpe '�.i Check Valve(s) �I Debris �1.Fill [..j No Obstruction <br /> �� Type of Obstructions(Describe)_��l�jf��' _��_��_ ¢_�.� �� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed7 ��Yes ',_I No Describe_ <br /> FORMATION <br /> PUMP <br /> ` If not known,indicate estimated formation log from nearby well or boring. <br /> .. TYPe-- � {-j��. �r . � <br /> -- -�---------- <br /> � Rema� .-�.;Not Present _ ;Other_ _ ._ <br /> METHOD USEDTO 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 /> /� <br /> in.from to ft �. ��Perforated [ �Removed <br />�. in.from to. . ..ft. i..!Pertorated , :Removed > <br />. `. <br /> Tyoe of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ,Yes �_�'�.No TN# �� <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> s f <br /> Grouting Material���a�y�����rom� to2_��_ ft,_,______ yards_�.____ bags <br /> ; from_.__ to_ fl.___. ._ yards _ bags � <br /> r __ irom__ _ . to_ _. ft._.___.. ___ yards ___ bags <br /> OTHER WELLS AND BORINGS <br /> �� REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? _Yes o How many?_ �� <br /> , - __.___ ---. . ..�. <br /> t� • �.;�., LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in acwrdance with Minnesota Rules.Chapter 4725.The information contained in this report <br /> � ��'���-`�""��'�---�^— � �,��, is true to the best af my knawledge. . <br /> �on St�x.?oIa t'ell '�rillic� Co,.Inc. I���'1 " <br /> --- -- --_ ----- - _ - - __ <br /> Licensee Business Name � License or Registration No. <br /> .. � '�^.�'. , . <br /> � � - 1?,-2 3-15 <br /> -;-;, —_t����� <br /> . -- -- _---- _ _ _. <br /> .CePr e ese`ntative Signature Certilied Rep.No. Date <br /> H Ji� Antonson <br /> LOCAL COPY 3 3 5 4 2 7 _ _ -- - -- - _ _ _-- _-- - -- � <br /> Name of Person Sealing Well or Boring <br /> HE-01434-14 IC#140-0423 5'�3R <br />