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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 <br />