2018 Well & Boring sealing Record

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HE -01434-15 ID# 53159 8r16R MINNESOTA DEPARTMENT OF HEALTH MinnesotaWell and Boring H `,� 5 15 5 6 6 WELL OR BORING LOCATION Sealing WELL AND BORING SEALING RECORD Minnesota Unique Well No. • 1 �J County Name Minnesota Statutes, Chapter 1031 or W -series No. P (kea- dank It not kn—) ';1�'Ii11'L 11'i Township Name Township No. Range No. Section No. Fraction (sm. -. Ig.) Date Sealed Date Well or Boring Constructed vrouv 117 [:i LU tvA;;r," S'/L' I GPS LOCATION - decimal degrees (to four decimal places) Depth at Time of Sealinft. Original Depth ft. Latitude Longitude IFER(S) Single Aquifer ❑ Multiaquifer STATIC WATER LEVEL L] Estimated Measured Date Measured Numerical Street Address or Fire Number and City of Well or Boring Location WE -S/C.-Y;- .3.449 Casco ClrC1: 0rO11J e1•' L'a [Water -Supply Well ❑ Monit. Well Show exact location of well or boring Sketch map of well or b ing in section with "Xti location, showing Env. Bore Hole Other ❑ ❑ ft.f below above land surface ❑ grid prix y N lines, roads, and buildin s. CASINGTYPE(S) Steel E] Plastic ❑ Tile E] Other WELLHEAD COMPLETION w E T !� --I j ;--- --;--- ------------ Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: El Basement Offset 'h Milen Well Pit ❑ Buried ❑ Well House --- -------------- _ ❑ Well Pit ❑ Other S ❑ Buried 1 Mile ❑ Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diameter 'I Depth Set in oversize hole? Annular space initially grouted? Property owners mai ing a dress if itfere t an we I lo'c*AiA AA#igicated above �� ^� in. from E to12sp—, ft. El Yes X No El Yes ❑ No ❑Unknown in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE Screen from _/ 9Q to/JeZ ft. Open Hole from to ft. Well owner's mailing address if different than property owner's address indicated above OBSTRUCTIONS Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction Type of Obstructions (Describe)x ✓L - Obstructions removed? X Yes ❑ No Describe GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO FORMATION PUMP ❑ Not Present Present, Removed Prior to Sealing ❑ Other If not known, indicate estimated formation log from nearby well or boring. Type 3Ar METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE o Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal Casing Diameter in. from to ft. ❑ Perforated ❑ Removed in. from to ft. ❑ Perforated ❑ Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? ❑ Yes No TN# GROUTING MATERIAL(S) (One bag of cement = 94 lbs., one bag of bentonite = 50 Ibs.) Grouting Material f�T�Liromto-1�� ft. yards bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑ Yes No How many? REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING 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 to the best of my knowledge. Dj.' OdODULA WEILL DRILLING CO., 1AC. 1691 Licensee Business Name License or Registration No. 558 ewr6 ,;,Representative Sig tore Certified Rep. No. Date [F LOCAL COPY JH 355566 Name of Person Sealing Well or Boring HE -01434-15 ID# 53159 8r16R