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HE -01434-17 ID# 53159 1 N 11/198 <br />MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br />WELL AND BORING SEALING RECORD MinnSealleso aoUnique Well No. <br />Minnesota Statutes, chapter 1037 or W-series No. <br />JL.— blank If not I-,,) <br />`? Q ' <br />H v '; i 6 <br />OR 80RING LOCATION <br />County <br />NIV� / (2�1] l,V / <br />�Aeei <br />To nship Name <br />D No <br />Township No. <br />I I ti <br />Range No. <br />_3 <br />Section No. I <br />33 <br />Fraction (sm. — Ig.) <br />04 <br />Date Sealed <br />— 5 20zz <br />Date Well or Boring Constructed <br />GPS LOCATION — decimal degrees (to four decimal places) <br />Latitude L C Longitude C C I T <br />Depth at Time of Sealing-1-5--ft. <br />Original Depth % ` C ft. <br />AQUIFER(S) <br />Single Aquifer ❑ Mulliaquifer <br />STATIC WATER LEVE , r,T <br />IU V ` L <br />� Measured Date Mea , L ❑ Estimated <br />ft. ❑ below ❑ above land surface <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />` /� ]� <br />pt <br />WELL/BORING <br />❑ Waler-Supply Well ❑ Env. Well <br />(Temp. Boring ❑ Other <br />Show exact location of well or boring Sketch map of well or boring <br />in section grid with "X.' location, showing property <br />N lines, roads, and buildings. <br />CASINGTYPE(S) <br />S <br />❑ Steel ❑ Plastic ❑Tile Other -,ZS �uLu,w (EM <br />------ -- j--- --- `---------- <br />WELLHEAD COMPLETION <br />W E <br />II I I <br />___ __ _____T <br />'h Mile <br />r 1�� <br />(j/ Q, <br />s "�+ 1 �lo� <br />Outside: PI1ess Adapter/Unit ❑ At Inside: B nt set <br />❑ Well Pit L1Buried Well House <br />❑wall Pit <br />ther <br />❑ Buried <br />�1 Mile <br />❑ Other <br />For temporary borings, provide additional location <br />information, a site sketch, and geology on a separate page. <br />CASINGS) <br />Diame er Dept Set in oversize hole? Annular space initially grouted? <br />in. from Io L ft. L] Yes N'No ❑ 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 />Prroop�perty owner's mailing address if different than well location address indicated above <br />275a �G Ej,yEy PW�/�q <br />SCREEWOPEN HOLE <br />Scr rom ft. le.�to ft. <br />A <br />U(�tio 6 <br />AM <br />WELL OWNER'S NCOMPANY NA E <br />It <br />OBSTRUCTIONS <br />❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill No Obstruction <br />Well owner's mailing address if different than property owner's address indicated above <br />t I <br />Type of Obstructions (Describe) <br />Obstructions removed? ❑ Yes ❑ No Describe <br />PUMP <br />of Present Present, Removed Prior to Sealing Other <br />❑ 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 />OZ <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 />sing Diameter <br />n. from ft. Pe d ❑ R oved <br />n. o ft.❑Perforated 171Removed <br />�AAIQ` <br />A/ <br />_ <br />2 <br />Z <br />\ <br />D <br />of Perforator <br />ype <br />VARIANCE <br />Was a variance granted from the MDH for this well? ❑ Yes [7kNo TN# �^ <br />GROUTING MATERIAL(S) <br />Grouting Material0' V �� from 0 to Z5 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 />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />0 4 —] <br />�p M M,� 3 l G <br />\\ c� <br />is true to the best of my knowledge. <br />E N N I S <br />Licensee B iness Name License or Registration No. <br />T 114,{ 34, 0) 1/23u�0) 1�2bl�� <br />v1�- ��j17 I h ow.. � � <br />kV 1 n I /' S � <br />Certified Representative Signature Certified Rep. No. Date <br />000LEVY <br />IMPORTANT-FILE WITH PROPERTY <br />PAPERS-WELL OWNER COPY <br />H ? �J 6 2 <br />`� <br />a e of Person Sealing Well or Boring <br />HE -01434-17 ID# 53159 1 N 11/198 <br />