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� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' /�Q�(`1 � <br /> W E L L A N D B O R I N G S E A L I N G R E C O R D Minn1egoNa Unique Well No. G!� ci �, <br /> Count Name or W-series No. <br /> Minnesota Statutes,Chapter 1031 ��ae�a e,a�k,�o,k�ow�� <br /> �✓l,�1.� i �(�1 <br /> To ship Name ownship No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> �17� v� '7 SGt�hl� ' I�UV. �, �C� J v <br /> GPS Latitude degrees minutes seconds Depth Before Sealing 7� ft. Original Depth_ ft. <br /> LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of ell or Boring Location � Single Aquifer ❑Multiaquifer <br /> ) v1 WElLI80RING �'Measured ❑Estimated Date Measured � � <br /> 4r�� ����� � ! � ����f' � `�Water-Supply Well �]Monit Well <br /> Show exact location of well or boring Sketch map of well or boring � j� <br /> in section grid with"X." location,showing property �,Env.Bore Hole []Other V�ft. �below ❑above land surface <br /> N lines,roads,and buildings. CASWG TYPE(S) <br />. . --'--- --'------`-- --'— �, <br /> �Steel f.�Plastic L]Tile ❑Other <br /> --�--- --�---'--`-----`-- WELLHEAD COMPLETION <br /> W : : : : ET <br /> � � � � Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> 'h M�ie �Pitless AdaptedUnit ❑Buried ❑Well Pit <br /> ; ; ; ; 1 <br /> ------ ------ ---�-----:- <br /> - ❑Buried <br /> ' ' S ' ' ❑Well Pit <br /> ❑Other <br /> f--1 Mile� r�}� �Other <br /> P TY OWNER'S NAM /COMPA Y NAM CASING(S) <br /> � � Diam er Depth Set in oversize hole? Annular space initially grouted? <br /> Prope ner's mailing ad i ditterent than well Iqcation address indicated above �in.from_�_ t0�ft. �Yes ❑No �Yes ❑No ❑Unknown <br /> 1 <br /> a��5 �2��-r I�� . <br /> �N � S 3� � in.from ro R ��Yes ❑No ❑Yes ❑No ❑Unknown <br /> W�-����. <br /> in.from ro ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WNER'S NAME/CO ANY NAME SCREEN/OPEN HO� /� <br /> �C� 1 �2 ` (�'�ry <br /> Well owner's mailing address if diflerent ihan property owner's address indicated above Screen from � to f O fl. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> �RodslDrop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) Y/�G �{ a^_1-�__ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? � Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. t^ <br /> TYPe�[��� <br /> �Removed ❑Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAH 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. ❑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 /> Grouting Material ���/J� / Of��l� �from_�. to�[� ft. yards� bags <br /> from to fl. yards bags <br /> from to R. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? '`I Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This weil 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 /> ; � )Y � [ !1 . SVG • ��a4.�� <br /> Licensee Business ame License or Registration No. <br /> Jt``a� ���;�c�' 1� � <br /> Certilied Rep�esentative Signat e Certilied Rep.No. Date <br /> ..,....w"�'� � <br /> �oer:,_coPv H Z��61 s �+1M .,,�[�"V P y1 S — — <br /> Name of Person Sealing Well or Boring . <br /> HE-01434-12 IC#140-0423 siosR <br />