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� <br /> �Q(ELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„� <br /> County Name <br /> WELL AND BORING SEALING RECORD Minne oNa Unique Well No. <br /> '��a�g�j,� Minnesota Statutes,Chapter 1031 o�r W-�enes�No. <br /> Township Name Township No. Range No. Section No. Fractian(sm-->Ig) Date Sealed Date Well or Boring Constructed <br /> ` Oro� 217 3 17 4 . �i ,. ,. � <br /> GPS Lalitude degrees minutes seconds � <br /> LOCATION: Depth Before Sealing �� ft. Original DepM ft. <br /> Longftude degrees minutes seconds ppUIFER(S) STAl1C WATER LEVEL <br /> Numerical SVeet Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> 71�, WELUBORING easured ❑Estimated <br /> $�Shareline vL� Or�IQ ry�(Nater Suppty Well ❑Monit.Well � � <br /> Show exact location of well or boring Sketch map ot well or boring �� <br /> in section gnd with"X" location,showing property ❑Env.Bore Hole ❑Other �%� ft. �low ❑above land surface <br /> N ���. li s,roads,anQG mgs. <br /> ,....`� ::,...:;k„�,:..,__x. .r� CASING TYPE(S) <br /> �1,� teel ❑Plastic ❑Tile ❑Other <br /> �� ���� <br /> W "f- 'Y' 'l" "1-' E � { �..� WELLHEADCOMPLETION <br /> � � ��j/���y } Outside: ❑Well House Inside: �asement Offset <br /> _Y_ ____ _l__ _�__ i � <br /> � � i i � <br /> �^"b �1 � . ❑Pitless Adapter/Unit ❑Well Pit <br /> --�- -i-- -i-- -�— I �__, ;r <br /> .1 J�7 a � +� ❑Well Pft ❑Buried <br /> S <br /> �rr--�'"+'-�4 �y'ci0 ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter + Depth � Set in oversize hole? Annular space initially grouted? <br /> Pr rty owner's mailing address if different than well location address indicated above �/. <br /> _� In.ffOm�t0�ft. ❑Yes �o ❑Yes ❑No ❑Unknown <br /> �� �n�� �vl�t �`� in.ffOm to ft. ❑Yes ❑No ❑Yes ❑Na ❑Unknown <br /> ' 4iinr�tnka, MN 553.91 <br /> in.ffOm to ft. ❑Yes ❑No ❑Yes ❑Na ❑Unknown <br /> WE L OWNER'S NAMFJCOMPANY NAME SCREEWOPEN HOLE <br /> Well owner's mailing address'rf di8erent than properry owner's address indicated above Screen from�t0�_ft. Open Hole from t0 ft. <br /> � � OBSTRUCTIONS <br /> � C�(Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe)�ybzhLt���"�L 1- �L�"� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 8S ❑ NO D2SCfib2 <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or bonng PUMP <br /> dCtft TYPe J«` 1'��urnl� <br /> �iRemoved ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> f9ifJo 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. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 Ibs.) <br /> .1t� / / <br /> Grouting Material,/U'Gp�'/ ��'+�'�'A fT from�t„�_to�ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICUITtES IN SEALING <br /> Other unsealed and unused weil or boring on propeAy? ❑ Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Dan Staddla t!eZ1 t?ri.l.Ifn�; Co,. Inc. 27172 <br /> Conhactor Business Name License or Registration No. <br /> 11-i7-05 <br /> r' d re tative Signatu e Date <br /> LOCALCOPY H <br /> 2��q p� Tim Stecner <br /> . •L�} Name o/Person Sealing Well or Boring <br />