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. <br /> 'yvELL OR BORING LOCAT1oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I <br /> � County Name WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. " - <br /> ����e��n Minnesota Statutes,Chapter 1031 or�W-�s�eri�es No_ <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> : Or0[t0 117 23 17 43�-t}t�94 ��. <br /> . <br /> GPS Lafilude degrees minutes seconds � <br /> LOCATION: Depth Before Sealing I� I ft. Original Depth ft. <br /> Langitude degrees minutes seconds ppUIFER(S) STATiC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Mul�aquiter <br /> �� �C��.J� � Or� WELUBORING Measured ❑Estimated <br /> 1 Water Supply Well ❑Moni[.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 ❑Otlier �ft. �below ❑above land surface <br /> es;roads, buildings. <br /> N ��,�.� 1�..,,.�.�. '�,,. CASING TYPE(S) <br /> - - - - - -- - -- u ,,,� Steel ❑Plastic ❑Tile ❑Other <br /> � � � � :� � _ <br /> W -�- -;-- -;-- --;— E }{ WELLHEAD COMPLETION <br /> � � � � j „ �,/ : <br /> Outside: ❑Well House Inside:g Basement Offset <br /> -'r- ---- -i-- --i-- � • e''�� 1C� / � <br /> � � � y� ❑Pitless AdapterNnit ❑Well Pit <br /> --�- -�— -i-- --�— i � �. <br /> � S ��� � �� ❑Well Pit . ❑Buried <br /> �-��»��, ,3���o ❑8��� <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter � Depth � Set in oversize hole? Annular space initialy grouted? <br /> Pro ner s� il ddress'rf different than well location address indicated above '2 �� � �/'� <br /> in.ffOm�t0�ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> ZSl7t7 [�n=�$ �`V1�� i.�IX in.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> �tirn7@Cdttka, 1� 55391 <br /> � in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL NER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> ///y v r <br /> Well owner's mailing address if different than properry owner's address indicated above Screen from�,[LS�t0�_ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) �f!�� /=7 p� } C�����2 <br /> GEOLOGICAL MATERIAL COLOR HAHDNESS 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 r"�(%(�JC� ��J f'y+}�,,^S <br /> Removed ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> (�No Annular Space ExisGs ❑ Annular space grouted with tremie pipe ❑ Casing Pertoration/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 o}cement=941bs.,one bag of bentonite=50 Ibs.) <br /> r �/�� �r <br /> Grouting Material ��T�'�O�L�from � to J�ft. yards L— 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 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 acxordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the besi of my knowledge. <br /> ik�n Stodola f?ell I?rillin_: Co, Iric. 27172 <br /> Contractor Business Name License or Regishation No. <br /> �_ _ <br /> _ � �.1-��)'� <br /> A es ntative SignaNre Date <br /> Tim Sterner <br /> ��A��PY H �4 3181 <br /> Name of Person Sealing Well or Boring <br />