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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I I % f -i (� <br />WELL OR BORING LOCATION Sealing No. ( U U <br />42 <br />County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br />" Minnesota Statutes, Chapter 1031 torm Uank w <br />r W s r esNol <br />%armepin <br />Township game Township No. Range No. Section No. Fraction (sm. -+ Ig.) Date Sealed Date Well or Boring Constructed <br />923 1 31 r C <br />GPS LOCATION - decimal degrees (to four decimal places)IF <br />Depth at Time of Sealing , ft Original Depth ft. <br />Latitude Longitude <br />AQUIFERS) STATIC WATER LEVEL <br />Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑ Mulliaquifer <br />W LL/BORING )tfAeasured Date Measured f1 %i% 1)A W ❑ Estimated <br />d Cristofori Crl prow 5 359 Water -Supply Well ❑ Env. Well <br />Show exact location of well or boring Sketch map of well or boring <br />in section grid with "X:' location, showing property ❑ Temp. Env. Well ❑ Other ft. Wbelow ❑ above land surface <br />N line; r�,As, and buildings. CASINGTYPE(S) <br />y ❑ Steel Plaslic E]Tile ❑ Other <br />i--- --i f WELLHEAD COMPLETION <br />W ET r <br />Outside: XPitless Adapter/Unit ❑ At Grade Inside: El Basement Offset <br />r f <br />le `- Well Pit ❑ Burled a <br />,k MiHouse <br />_ - <br />--�--- --�--- -- �-- ---%- El Well Pit <br />n Other_ <br />S Jj <br />—t Milan 0-)y <br />�r�"Y,atj <br />For multiple temporary environmental wells, provide additional location <br />information, a site sketch, and geology on a separate page. <br />L] Buried <br />❑ Other <br />CASING(S) <br />Di er / Depth Set in oversize hole? Annular space initially grouted? <br />m. from_ to �J ft. ❑Yes iNo ❑Yes ❑ No ❑Unknown <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Property owner's mailing address if different than well location address indicated above <br />SCREEWOPEN HOLE 0 <br />Screen from i05 to / 6 ft. Open Hole from to p. <br />WELL OWNER'S NAMEICOMPANY NAME <br />OBSTRUCTIONS <br />❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill Wlo Obstruction <br />Type of Obstructions (Describe) <br />Obstructions removed? ❑ Yes ❑ No Describe <br />Well owner's mailing address If different than property owner's address indicated above <br />PUMP <br />Present, Removed Prior to Sealing Other <br />/t �fdot Present ❑ g ❑ <br />Type <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TO <br />If not known, indicate estimated formation log from nearby well or boring. <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 Perforation/Removal <br />asing Diameter <br />in. from to ft. ❑ Perforated ❑ Removed <br />In. from to ft. ❑ Perforated ❑ Removed <br />Type of Perforator <br />VARIANCE <br />Was a variance granted from the MDH for this well? ❑ Yes No TNN <br />GROUTING MATERIAL(S) (One bag of cement = §4 lbs., one bag of bentonite = 50 lbs.) <br />Grouting Material,A/KQri5cof"L//from d to/ ft_ yards bags <br />from to ft. yards bags <br />from to ft. yards bags <br />OTHER WELLS AND BORINGS <br />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 />Don 3todola Well Drilling Co,. Inc. 1691 <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />Licensee Busines 11Name License or Registration No. <br />� <br />/ - t% ' 1 <br />e rdsentati ig a ure Certified Rep. No. Date <br />fn <br />LOCAL COPY <br />H�j r/1 HU <br />7 0 0 `y' L <br />Name of Person Sealing Well or joring <br />