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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealmg No. ell and Boring �„' °"� � � :J � Q
<br /> County Na�
<br /> WELL AND BORING SEALING RECORD Minnesota Unique Well No. J o
<br /> or W-series No.
<br /> Minnesota Statutes, Chapter 7031 Lu8veb1��k„�o�k�w�, SGj /(,�/
<br /> To ship N e Township No. Range No. Section Na Fraction(sm.�Ig.) Date Sealed Date Well or Boring Conshucted
<br /> � � - �. .� �� ��
<br /> GPS LOCATION- decimal degrees(to four decimal places) i
<br /> . Depth Betore Sealing_1�� it Original Depth_._.___ . ft.
<br /> Latitude_.__ _ _ Longitude __________ - ---
<br /> A UIFER(S) STATIC WATER LEVEL �
<br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ;_�Multiaquifer � , ,�r
<br /> WEWBORING i Measured ', �.Estimated Date Measure �_
<br /> e �� � � r� �5� ;Water-Su I Well � � /
<br /> pp y ���MoniL Well
<br /> Show exact location of well or boring Sketch map of well or or����qqqggg �( ,-
<br /> in section grid with"X:' location,showing prop rt� �.�Env.Bore Hole [j Other __��_ _ ft. /ry below �L!above land surface
<br /> N lines,roads,and buildi g CASING TYPE(S)
<br /> __'___ __i___ ___`__ ___�__ M..
<br /> ,��� �.Steel f �Plastic ��_�Tile !_i Other______
<br /> � --''-'--�--- --+-- ---`-- WELLHEAD COMPLETION �
<br /> , W ; ; ; � ET _
<br /> ,
<br /> � � � � � 'h nniie -�Buried _�Basement Ofiset '
<br /> _ _____ ___ __ __ _ _ Outside: . i Well House �_,At Grade Inside: '
<br /> .� ; ; f ' dless A p dUnit -� �._, ell Pit �,
<br /> �P� da te � �W
<br /> 1 _ ; �Buried
<br /> ' ' ' S � i_j Well Pit
<br /> s .¢' _ �_i Other
<br /> i 1 Mile--� :� �� �.�_1 Other — --�------- �
<br /> PROPERTY OWNER'S NAME!COMPANY NAME CASING(S)
<br /> A; Dia �� � Depth � Set in oversize hole? Annular space initially grouted?
<br /> Property ownei's mailing�a dress if different than well location address indicated above .� in.fromQ t ft. I_�Yes '�l'.No �_I Yes �No ,_�,Unknown
<br /> ��—
<br /> �o�
<br /> _ __ln.from to_ ft. !]Yes �'�No _;Yes ,_;No i_j Unknown
<br /> in.from_ ro_.____ft. �Yes ❑No .�Yes �_�No j_l,Unknown
<br /> WELL OWNERS NAME/COMPANY NAME SCREEWOPEN HOLE
<br /> , !
<br /> Well owner's mailing address if different than property owner's address indicated above SCreen from_�� . _to_S�___it. Open Hole from__._______ to_______ft. �
<br /> OBSTRUCTIONS
<br /> �RodslDrop Pipe '-]Check Valve(s) �I Debris ��,_i Flll �No Obstruction
<br /> Type of Obstructions(Describe)__ .__._ ____ __ _ ___
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obshuctions removed? '�.]Yes I )No Describe
<br /> FORMATION
<br /> PUMP
<br /> If not known,indicate estimated formation log from nearby well or boring.
<br /> , Ls` e •`..J JSg TYPe___—_
<br /> ----- --_-- ------
<br /> f_I Removed �Not Present ��,J Other___ __. _ __ _ __ _ _ __ _ _
<br /> �t
<br /> METHOD USEDTO 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 �j Perforated i I Removed '�,
<br /> `� __in.from to ft. i_J Perforated �Removed ���
<br /> — ___._�_.------ ------- --
<br /> Type of Perforator _ ;
<br /> VARIANCE
<br /> Was a variance granted irom the MDH for this well? ,�.'.Yes �,No TN#
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> � r'`
<br /> `y �7 � : �.
<br /> ; Grouting Materiati+'��i���,�/�_ from_.Q _ 1��`j�,__ ft. yards_jl _ __ bags ��
<br /> ._._ from to______ ft.____ yards_ __ bags
<br /> _ _ ___ from_____ to ft.__.___,___ yards ___ bags �
<br /> OTHER WELLS AND BORINGS
<br /> 'i� REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ��_ ''Yes .No 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 best of my knowledge.
<br /> tk�n Sto�ola �1e11 [�cil lin� Co,.Inc. 16�1
<br /> ---- - �-— —- ---- ---- __-------- -------_ g-----—
<br /> Licensee Business ame License or Re istration No.
<br /> ; % ,.�
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<br /> ,� :�'�'` � �� � /� .30 . �s ��
<br /> , f :� - -_ _ - --------___ _ --
<br /> � e�r '�d�REfp�'esentatroe Sgn '}e Certified Rep.Nn. Date
<br /> 4
<br /> �,,."
<br /> l,; ,,
<br /> LOCAL COPY ---- = �i._- ='-'- _ _ ---
<br /> " 3 3 5 �9 8 Name ol Person Sealing Well or Bor� �
<br /> ,�- _ �
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<br /> HE-01434-14 IC#140-0423 � , 5�i3R
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