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._.:,l��:i�..:. <br /> WELL oR BORING LOCA7iON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' ��c� <br /> County Name <br /> WELL AND BORING SEALING RECORD MennesoNa Unique Well No. J <br /> �� i� Minnesofa Statutes,Chapter f031 or W-series No. <br /> ��ea.e eie�x n�m w�own� <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> 4rono 117 23 0 32 24 ',. ',. (' p�' <br /> � , <br /> GPS Latitude degrees minutes seconds Qj� Q/� <br /> LOCATION: Depth Before Sealing L"" ft. Original Depth s-�`-' ft. <br /> Longitude degrees minutes seconds pQU1FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and Ciry ot Well or Boring Location Single Aquifer ❑Multlaqu'rfer <br /> WELUBORING �Measured ❑Estimated <br /> �Water Suppty Well ❑MonR.Well <br /> Show exact location of well or boring Sketch map ot well or boring <br /> . in section grid with"X" location,showing property ❑Env.Bore Hole ❑Otlier �tt. �below ❑above land surface <br /> lines,roadS and buildings. <br /> N ���' CASING TYPE(S) , <br /> - - - - - -- - -- �•._,,:_.,F�j t�.,i�r.�'�`.i Jt",��.,. <br /> ..�.rrw� ��" Steel �Plastic ❑Tile ❑O[her <br /> W -- - -i-- -i-- --i-- E ��. � .�.. �. .r. .. , WELLHEAOCOMPLEl70N <br /> -'r- ---- -;-- --i-- � ^ �.{�O�i�/,f3r� � ��81�' ❑WeIlHouse Inside: ❑BasementOffset <br /> �� _ , � � ❑Pitless AdapterlUnit ❑Well Pit <br /> —�- -�— -i-- --�-- � . � . . .� <br /> a <br /> �+-���� ❑Well PR ❑Buried <br /> �—�'"'�'—�' �Q'Buried <br /> I� <br /> � PRaO,P,,ERTY,tOWNER'S NAM�E�/.C.�O,M.PANY NAME CASING(S) <br /> �:�V�11 a� .7VEfD Diameter Depth Set in oversize hole? Annular space initialty grouled? <br /> Property owner's mailing address if different than well location address indicated above /t <br /> �_ in.ffom� to � ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> 11G01 Cty Rd 3 <br /> a�AipR.117$� MN 55343 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> �; WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> I��_ + t <br /> Well owner's mailing address if diHerent ihan property owners address indicated above Screen from�5,�t0�ft. Open Hole from 10 1I. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe)_��c1�t������'��;f s i <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ NO DBSCflbO <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or bonng PUMP <br /> �C�f� � � Type <br /> ❑ Removed Not Present ❑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 PerforatioNRemoval <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 bentonite=50 Ibs.) � <br /> / <br /> Grouting Materiay�,{��%�.�(1"��� from�_to�2�ft. yards � bags <br /> trom to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> �� REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes o 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 is <br /> true to the best of my knowledge. <br /> llonseodola i�ll Drillin,� ca., rnc. z7172 <br /> Contractor Busi ss ame � 7 License or Regist�ation No. <br /> ,^" i <br /> . <br /> /-��� �..J v.--�.�� � — <br /> o presen abve Sign e Date <br /> ,` <br /> i <br /> LOCAL COPY <br /> H 3 5'�2 5 : _ �,_ .,._,: ,1-,.__ <br /> Name o/Person Sealing Well or Bonng - <br />