WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �-��315�:'
<br /> County Name WELL AND BORING SEALING RECORD Mennle90 aoUnique Well No. �
<br /> Minnesota Statutes, Chal1ter 1031 or W-series No.
<br /> ��� •� Y Leavx blank ii nat known)
<br /> 1
<br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
<br /> `' C1CQ!'!O 1 Z� 23 ZO StS !� �1C�F � � .+
<br /> GPS LOCATION-decimal degrees(to four decimal places) < <
<br /> Depth Before Sealing_��ft. Original Depth�__�_�___fl.
<br /> Latitude_._ _ Longitude _ _____
<br /> IFER(S) STATIC WATER LEVEL
<br /> Numerical Street Address or Fire Number and City of Well or Boring Location . ingle Aquifer '�1 Multiaquifer ,�,�/ }�w
<br /> 3745 �oreline �r� \7C�Q 55391 ��ORING �leasured ! Estimated DateMeasured�=,At�`r �/I'��
<br /> � i Water-Supply Well � 1 Monit.Well � �
<br /> : Show exact location of well or boring Sketch map of well or boring ��Ern.Bore Hole '_.;Other �_ft. �below i;��]above land surface
<br /> � in section grid with"X" location,showing pro erty �� . - � -.. �.
<br /> lines,ro d'�,and b � s. '
<br /> , N ��.4; j,,.. ��.... , � CASINGTVPE(S)
<br /> , , . _ �. . R ,
<br /> �--- ---�- -�-
<br /> Steel [ I Plastic [1 Tile ❑Other_ ___ __ __ ____ ____
<br /> --- - -- ta. WELLHEAD COMPLETION A/ �
<br /> e{ t yo� �o;
<br /> W __ _ _ E T / ; Outside: �Well House �.J At Grade Inside ..�;Basement Otfset � °.)
<br /> ; ; ; � �`� v�
<br /> , , , , F Miie e ❑Pitless AdapteuUnit Buried �Well Pit
<br /> , � .
<br /> .- --�-- --�-----:- ..�t J c�T1- ��5 :
<br /> .' , , , , - ` ]Buried O
<br /> ' ' S ' ' �Well Pit �O 5
<br /> �i Other IQ�,. r
<br /> �—i M�ie—� �Other_._ ---. ..._____ --.Tv—
<br /> ----- - tio
<br /> PROPERTY O�WLNE,,R'S NAME/C•O�M'PALN.Y,�.NAME nf,,�� �L CASING(S)
<br /> �, (^ ,,�it��" Cd iN„�ttic[$1] �,.tiUrLi I Diamet�� �pth ,.+ " Set in oversize hole? Annular space initially grouted? �,
<br /> Property owner's mailing address if diflerent than well loca�ion address indlcated above in.from � to J fl. � �'��.Yes No Yes � �
<br /> �. _ _.__��_ , � �_� U No ��Unknown
<br /> � __in.from_ to___ fl. I_�Yes ;]No [,Yes r No j Unknown
<br /> _. in.from to _fl. j Yes [;No []Yes ❑No ❑Unknown
<br /> WELL OWNER'S NAMEiCOMPANY NAME SCREEWOPEN HOLE
<br /> i i
<br /> ��� Well owner's mailing address if different than property owners address indicated above Screen from to ft. Open Hole from��to��. ft 9
<br /> OBSTRUCTIONS
<br /> '�RodsiDrop Pipe , ,Check Valve(s) L I Debris 'Fill ! No Obstruction
<br /> -> Type of Obsiructions(Describe)�/�//lxi�_�._�� ¢��m�
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ' ;No Describe
<br /> FORMATtON - --- ----- �--- - --
<br /> PUMP
<br />� If not known,indicate estimated formation log from nearby well or boring. Q (� ��
<br /> ' TYPe--�Uf1__�_��� .
<br /> r-
<br /> �J<
<br /> - — --- --
<br /> � , i�� '-`,� �-j Removed �: '�,Not Present �__J Other '
<br /> i
<br /> ..�y�--s��--.. � '`� ' .METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
<br />� j�No Annular Space Exists ; Annular Space Grouted with Tremie Pipe '�I Casing PeriorationiRemoval
<br /> r�
<br /> � in.from to fL (-�i Perforated � 'Removed -
<br /> j -
<br /> ., ,___ �__ __in.from_ _ to_________R �, ]Perforated � �Removed �
<br />..- Type of Perforaror----- ._...._. ___.___. ..---- -.
<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 /> Grouting Materiai_����_��om��o�='/J 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,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? __.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
<br /> is Irue to the best of my knowledge.
<br /> Don St«iola Well Drilli.ng co., Inc. 1691
<br /> - - __ -- _ _____ _ -- - -
<br /> Licensee ine N e S License or Registration No.
<br /> ` _ ''� '.--.
<br /> � ��"'� - �J .:
<br /> �. y = - �
<br /> ,.,�.,,.'-. ;" - ,. �
<br /> -- -- - _ __--- -- �.
<br /> C ied Re resentative Sig 'Ye Certilied Rep.No. Date
<br /> , H ��{1 �-1( � , _, :
<br /> {- LOCAL COPY � ol,J ��O ------ --- —�--- .:__.-�{..'l�� _.�r:,�J,,jJ!'Y' `�'' .
<br /> Name of Person Sealing Well or Boring � �� �
<br /> HE-01434-14 IC#140-0423 ! 5�i3R
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