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t WELL OR BORING LOCArION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �, <br /> ��� WELL AND BORING SEALING RECORD Minn'esota Unique Well No. ' <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> t�����.,,� <br />��� Tovmship N Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> �ra�na li�-2 33-4 -� '. '. '. , tG <br /> GPS �-alitude degrees minutes seconds /_`, � � <br /> LOCATION: Depth Before Sealing �� ft. Original Depth ft. <br /> Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑MuHiaquifer <br /> ELLBORING Measured ❑Estimated <br /> �Water Supply Well ❑Monit.Well <br /> SFaw e loca o of we or onng e ch map of well or boring / <br /> in section grid with"X" Ixation,showing property ❑Env.Bore Hole ❑Other i(�I (t �below ❑above land surface <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> �Steel ❑Plastic ❑Tile ❑O[her <br /> W --f- -�-- -�-- --�-- E .,%� WELLHEADCOMPLETION <br /> � 47�� ��`�� Outside: ❑Well House Inside: ❑Basement O(fset <br /> -,�- —�- -r- -i-- - <br /> 1��M ,J �itless Adapter/Unit ❑Well PR <br /> --�- -�- -i-- -�-- I ti .. " � <br /> 1 ❑Well Pit ❑Buried <br /> S <br /> N��'"�'�' . � �y,t-. . ❑Buried <br /> L <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> .� Diamete�� t Depth { Set in oversize hole? Mnular space initially grouted? <br /> Property owner s mailing address if diNerent than well location address indicated above <br /> � in.ffOm� t0��it. ❑Yes QrNo ❑Yes ❑No ❑Unknown <br /> 38�� 88 a� �\ <br /> in.ffO�T1 t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 'i <br /> WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> � • � <br /> Well owner's mailing address if different than property owners address indicated above Screen from/��t0�[�._ft. Open Hole from t0 ft. <br /> - o�c� <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Y0S ❑ NO DOSCfibO <br /> FORMATION <br /> If not krawn,indicate estimated formation log from nearby well or boring PUMP . <br /> , .t Type <br /> ''-' r�'"`�� . ❑ Removed Not Present ❑Other <br /> i � <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BOHE HOLE: <br /> �No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/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 of cement=94 Ibs.,one bag of bentonile=50 Ibs.) <br /> Grouting Material/`�L�f�i���/from�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,DIFFICUITIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFlCATION <br /> This well or boring was sealed in accordance with Minnesofa Rules.Chapter 4725.The infortnation contained in this report is <br /> true to the best of my knowledge. <br /> Ck� Stodala t�el.l Drilliceg Co., Inc. 2717'2 <br /> Contractor Business Name License or Registration No. <br /> lr.,,,- ..r �,�t <br /> �� A r res`e"nta SignaNr Date <br /> 0 <br /> ��. <br /> H 244441 - �,r ,, f � <: , ,� <br /> LOCAL COPY ;r-: _ <br /> Name of Person Sealing Well or Boring <br />