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�. MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 'Z �`� WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Minnle9oNa Unique Well No. H � "M��` ��` � County Nar►e � � Minnesota Statutes, Cha ter 1031 or W-series No. P (Leave blank I�not kn wn) � Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed `�. 7 ( � � Tn (!/v l< GPS LOCATION- decimal degrees(to four decimal places) ) � Depth Before Sealing /��/ ft. Original Depth fl. Latitude Longitude A UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer r�I,M J��► /�- 72�j �i!t�}Z A V� P,T� f}r��(� �j��!11 WELUBORING �Measured ❑Estimated Date Measured�ri/71�' !.rC/ Water-Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or boring / in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other /l.f�/�l_ ft. �elow ❑above land surface �` in s,roadS; nd build [y N ..-}. �....._.. :,��,tiR �7 CASINGTYPE(S) '-'-'--'y----`-- --'-- ' --�-��-��--��`-----�-- ELLHEADCOMPLETIONIIe th � ❑S el P ❑T' ❑O er 1'�C(��,��U�� , ' W W � � � � E � N _� � � � T Outside: ❑Well House At Grade Inside: ❑Basement OffseA I I f O � ?0 I� • - ;--- --�--- -�----�-- 'hMile� Pitless Ada ter/Unit ❑Buried ❑Well Pit ��UL : ; ; : 1 � P --�-----;-----�-----�- ❑Buried ^ .. ' S ' ❑Well Pit �Other v'��ORO'vo F-1 Mile-{ ❑Other PROPERTY OWNER'S NAME/COMPANV NAME CASING(S) �� ' F7 DiameJe�� r Depth / Set in oversize hole? Annular space initially grouted7 Prope ty owner� ailing address if different than well location address indicated above c,J � / in.from d to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown �� `tt� A�� in.from to R. ❑Yes ❑No ❑Yes ❑No ❑Unknown �rorx�, t�1 55�91 in.from ta ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE I A Well owner's mailing address if different than property owner's address indicated above Screen from�to_J_�,�_ft. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �o Obstruction �� Type ot Obsiructions(Describe) GEOLOGICAL MATERIAI COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION PUMP -� If not known,indicate estimated formation log from nearby well or boring. ,r .� Type �`�` � ��Removed �Not Present ❑Other - MEJHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: ' BNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal /� in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated [f Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TNti_ GROUTING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite=50 Ibs.) M '�' r Grouting Material�� F//��/V�from U to�_�"�� R. yards /� bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes � No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report � is true ro the best of my knowledge. '-kkan "todola t�Tell T�ri].lic�; �o,. Inc. 1Czn1 Licensee Business Name License or Registration No. i /` �_ ;; � �,, "..��`j,,,�" � r- - � �.- ...P�- i � �ettiKed Aepresenta6ve Sign twe Certilied Fep.No. Date r-� u Q F' � �Y`'. ��} :�'Y� LOCAL COPY n � � („j,<�,�l�J Name ol Person Sealing Well or Boring HE-01434-14 ID#53159 v 5/13R