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(Mti ' y sr <br /> URI <br /> , , '� w l R 'irCT ...r • 6 <br /> • <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 231048 <br /> WELL OR BORING LOCATION Sealing NO. <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> I . _ ' Minnesota Statutes,Chapter 1031 or W-series No. <br /> P te."etw�nro awl <br /> - "�% r• Date Well or Boring Constructed <br /> Township Name Township No. Range No. Section No. Fraction(sm-a-Ig) Date Sealed <br /> L <br /> J Or. I C • 20Oli' Ltr krDv' r <br /> U 1,i i;i O j 1 'N .1 j Vii/ _ <br /> GPS Latitude degrees minutes seconds Depth Before Sealing I7. ft. Original Depth ft <br /> LOCATION: <br /> Longitude degrees minutes seconds Apu IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ,L,�t.�'Single Aquifer ❑Multiaquifer• 2/ <br /> WELLBORING L/Measured 0 Estimated <br /> _4-1-)11--)L-' 1 ,1,/ )j I ;i I j ,' �' :j'_;1 t i Y. [/Water Supply Well ❑Monit.Well __ <br /> Show exact location of weltor boring ' Sketch map of well or boring r� ft. �elow ❑above land surface <br /> location,showing property 0 Env.Bore Hole 0 Other <br /> in section grid with"N 4 <br /> lines,roads,and buildings. CASING TYPE(S) <br /> N <br /> [Steel 0 Plastic ❑Tile 0 Other <br /> WELLHEAD COMPLETION <br /> E . <br /> W I • <br /> --+---+---+-----4, ' Outside: 0 Well House Inside: 0 Basement Offset <br /> t' Jam. <br /> t + t � &" ! VPitless Adapter/Unit ❑Well Pit <br /> ( \// ❑Weil Pit ❑Buried <br /> I Mere / 3 ❑Buried <br /> PROPER ...../) <br /> •rr a • • E/COMPANY NAM CASING(S) <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above 6•' in.from D to W ft. ❑Yes Lit No ❑Yes 0 No [/Unknown <br /> 1 in.from 6 to I D ft. ❑Yes YNo ❑Yes ❑No 'Unknown <br /> in.from to ft. •❑Yes 0 No 0 Yes 0 No 0 Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if diflerent than property owner's address indicated above <br /> Screen from I-.0 to 1,4- ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe'--.J .Xleckyalve(s) 0 Debris 0 Fill p'No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS <br /> TIA ONR FROM TO Obstructions removed? 0 Yes 0 No Describe <br /> FORM <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring VA" <br /> Iii <br /> �V �1,,!fi t1 <br /> 0 Type / A L <br /> DY1F-1-- �_,;1 v'Removed 0 Not Present 0 Other <br /> "`;rd !H,D 154 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> [/No Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> Type of perforator r• <br /> ❑ Other <br /> GROUTING MATERIAL(S)(( (Onej, bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> .! ! 1 11'il\i iYl from11 <br /> Grouting Material 1<I( 1 � to ��'•� ft. yards `�; bags <br /> from 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? 0 Yes a 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 is <br /> true to the best of my knowledge. <br /> v., . 1 !L Dz-i ( (�1 Co .Y <br /> U J-?n <br /> Contractor Business Name License or Registration <br /> n No. <br /> il1)ir <br /> Date <br /> Authorized Represer$Ative Signature <br /> L, 211 nAR 1 /i,) ! :sn,_l-i - <br /> _ <br />