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, WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � ���O�
<br /> ' Count}�Narse •
<br /> WELL AND BORING SEALING RECORD Mnnle9oa�UniqueWellNo.
<br /> f' Minnesota Statutes,Cha ter 1031 or W-series No.
<br /> • �7'tP1^t)iil P ��aa�eeia�ea�mk�ow��
<br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
<br /> ��.� ?�. '�^ x^' �`j' 3 t�')A ►�
<br /> "c�nn _ ,,,< .�.
<br /> �j �
<br /> GPS Latitude degrees minutes__ seconds Depth Before Sealing ��/ ft. Original Depth ft.
<br /> LOCATION: � Longitude degrees___ minutes seconds
<br /> AyIUIFER(S) STATIC WATER LEVEL
<br /> Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Multiaqui(er
<br /> r, � rT t� r,�,,�r,� W LL/BORING Measured �1 Estimated Date Measured {�����'� ���
<br /> 3515 . i_xt.� AV� • Cn[lO �� : �1 Water-Supply Well �=1 nno��t wen
<br /> � Show ezact location of well or boring� Sketch map of well or bon i-� ? ' �/ ��
<br /> � in section grid with"X" location,shov{ing prp per ,_Env.Bore Hole [.j Other___ �� R �}below ❑above land surface
<br /> �I��$,roads,tln�UGdin�s.�
<br /> N ��_ tj..r CASINGTYPE(S)
<br /> , _.
<br /> . -''----'_' -_`-''--'"
<br /> � ��,Steel [j Plastic L]Tile IJ Other ______
<br /> --'--- --�-- ---`-----'"- WELLHEAD COMPLETION �2
<br /> � w ; ; ; � ET
<br /> �� � � � � !]Well House
<br /> .r __,__ __,_____._____r__ Outside: []At Grade Inside: ❑Basement Offset �
<br /> � ��'h M�ie + ❑Buried ❑Well Pit
<br /> 1 t �Witless Adapter/Unit
<br /> ,, ` ❑Buried �
<br /> ' S ' � ! ❑Well Pit '
<br /> �� � { �]Other_ n
<br /> �--1 Mile� � f r]Other
<br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
<br /> �l r� .� Dia�]e�er ♦ Depth . Set in oversize hole� �AittcuYgY�s�S�Ce-initially grouted?
<br /> Pro ert owner's mailin address if different than well location address indicated above �/ ��
<br /> P Y 9 —( in.from U _ to ��� R ��Yes �No r]Yes ❑No ❑Unknawn ��
<br /> _
<br /> ��: in.�rom to tt. [j Yes ❑No ❑Yes ❑No , q Unknown
<br /> +;:�>tac =5 s.,, .. �,
<br /> ` _ . . . . ...;..g .
<br /> in.from to ft �1 Yes ❑No ❑Yes ❑No ❑Unknown
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
<br /> ' 2r . .
<br /> ,. y. •._ ., ,
<br /> Well owner's mailing address it diNerent than property owne�'s address indicated above ' SCreen from��__. � [o�� ��(t. Open Hole from _ t0�"� � ���(�.� _
<br /> .. . .,.. .. - � OBSTRUCTIONS
<br /> j]Rods/Drop Pipe ❑Check Valve(s) [��Debris �;-;Fill ��No Obstruction
<br /> _ .. .-:n*, ..
<br /> u
<br /> � Type o(Obstructions(Describe)
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �]Yes [J No Describe
<br /> FORMATION
<br /> PUMP . ,�. �. 'i=".- � --_ ., ..
<br /> If not known,indicate estimated formation log from nearby weli or boring. � -� - � - � • �-
<br /> ' t • Type `
<br /> .. ,: .-..,. / ,
<br /> ��-"� �� '� �� ��Remaved �Not Present ❑Other
<br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND�BQRE:,NOt;E r "'-� �
<br /> No Annular Space Exists [J�Annular Space Grouted with Tremie Pipe i�Casing Perforation/Removal z
<br /> � _,_____in.from to ___.__ft ❑Perforated ��Removed
<br /> in.from.----.---_------to ft. - �]��Perlbrated�'."� [ I'Removed
<br /> Type of Perforator___
<br /> ( �Other--------- ------- -- y
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> >' � r
<br /> i
<br /> Grouting MaterialJtJ'�!J%CLJ}'1�-L.'T from � to ��� ft.__ _ yards�U bags
<br /> Y
<br /> from to ft. yards bags
<br /> from_. to ft. _ yards bags
<br /> i OTHER WELLS AND BORINGS �+.
<br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? i_���Yes I�Jo 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 true to the besf of my knowledge.
<br /> 'km Stac�ola ��ell Drillin�; Co,. inc. 1�91
<br /> Licensee Business N`; ���� � License or Registration No.
<br /> . , ,;, �/� ---" . � �
<br /> ..,,,, ,�` �� ,�,, - � ...�
<br /> C il(edFepresentative Signature s Certified Rep.No. Date
<br /> ` _ ^ t
<br /> \
<br /> `�. � ��__,.�.,.��-.�,�.�r�,.t-�..
<br /> ��.��., H 312 0 0� ---- - - -
<br /> Name of Person Sealing Well or 8 ing
<br /> HE-01434-13 IC#140-0423 - Sii2a
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