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WE�L OR BO'RI�IG lOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H ��4 0 2 4 <br /> � ��a�� WELLAND BORING SEALING RECORD SealingNo. <br /> Minnesota Unique Well No. <br /> �x��pi� Minnesota Statutes,Chapter 1031 or W-�seri es�No. f � �_� j �J �` <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> Oron� 118 23 26 �,. �,. �,. � <br /> GPS LaMude degrees minutes seconds .,, � r � <br /> LOCATION: �eptli Before Sealing ��+-~ ft. Original Depth `�a ft. <br /> Longitude degrees minutes seconds pqUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aqu'rfer ❑Mul�aqu'rfer <br /> �570 Vt[l A� � �� Sg356 WELUBORING �Measured ❑Estimated <br /> Show exad location of well or boring . of well or boring �Water Suppy Well ❑Montt.Well � <br /> in section grid with"X" location, howing properry ❑Env.Bore Hole ❑Other �4 ri. �below ❑above land surface <br /> N lines,r s,and buildings. CASING TYPE(S) <br /> -Y- -T- -i-- -i— f <br /> : <br /> ; ; ; ; 0�.��1. Steel �Plastic ❑Tile ❑Other <br /> —�- -�-- - -- --i-- � WELLHEADCOMPLE110N <br /> W E <br /> TT Outside: ❑Well House Insfde: ❑Basement Offset <br /> _Y_ ____ _l__ _�__ I <br /> �^� `�Pitless Adapter/Unit ❑Well Pit <br /> --�- -i-- -i-- -i-- I <br /> 1 ❑Well Pit ❑Buried <br /> S <br /> �—'""�'—�` _ - � � ❑Buried <br /> PRDP�RTY O�yN�R�'S�NA�E/COMPANY NAME CASING(S) � <br /> `1Ej�Zt1 am Diameter Depth . Set in oversize hole? Annular space initialiy grouted? <br /> Property owner's mailing address'rf differeot than well location address indicated above � r.'�.�`r <br /> � in.from � t0�ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> in.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown E <br /> 1 <br /> � <br /> in.f�om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 1 WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> r � <br /> � Well owner's mailing address if different than property owner's address indicated above Screen from ���✓ t0 j� ft. Open Hole from t0 ft. � <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction � <br /> '� j � i <br /> Type of Obstructions(Describe) - i N.tl�% I-Ii1+G p- �1� .{] <br /> GEOLOGICAL MA7ERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑ No Describe � <br /> FORMATION <br /> PUMP ` <br /> If not krwwn,indicate estimated formation log from nearby well or bonng � <br /> �r ' Type ">c�G' �c.��'r' .� <br /> '�J� � �"'' '�'Removed ❑ Not resent ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE 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 MATERtAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> 6 /"•iL' t /=r,� <br /> Grou[ing Material/��f - ��'��'�� from�to�ft. yards �.�L— bags <br /> from to ft. yards bags <br /> trom to ft. yards bags <br /> OTHER WELLS AND BORtNGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Ves �No How many? <br /> LICENSED OR REGISTERED CONTHACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The intormation contained in this report is <br /> true to Uie best of my knowledge. <br /> Ib� Scoc�ola W�11 �rillin� Co., Inc. 2'71.72 <br /> Contractor Busi N License oi Regishation No. <br /> .. r <br /> � +�,�1 ' �_ r.l.�..% <br /> o' res¢taWe nature ' Date <br /> LOCAL COPV H 2�4�2 4 � =-a.�,. � r �..L�,Y..., <br /> Name o/Person Sealing Well or Boring <br />