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• <br /> WELL OR BORING LOCATION Sealing No. <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„� g 6 g 9 <br /> County Name WELL AND BORING SEALING RECORD MinnaoUnique Well No. <br /> j�` ' a Minnesota Statutes,chapter 1031 or W-series No. <br /> j ,[ (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.— lg.) Date Sealed Date Well or Boring Constructed <br /> O O OO 117 23 07 S SE'S " /30/22 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 0 ft. Original Depth ft. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location DI Single Aquifer ❑Multiaquifer t ;fi <br /> 4041 A d • . i7 S ri E DRIVE, °R o o s WELUBORING Measured Date Measured /], /22 ❑Estimated <br /> A Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring Ali .) )..ititeii map of well or boring 44 <br /> in section grid with"X" location,showing property ❑Temp.Boring ❑Other ft. 0 below ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> y <br /> A Steel ❑Plastic ❑Tile ❑Other <br /> -` `-- WELLHEAD COMPLETION <br /> W E <br /> - T Outside: li Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> I <br /> 'k Mile ❑Wet Pit ❑Buried ❑Well House <br /> i ❑Other ❑Well Pit <br /> s ❑Buried <br /> f —t Mile --1 <br /> ❑Other <br /> For temporary borings,provide additional location 4.I CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> PR a O R' P.NY_LI E,.,, , in.from to ft. ❑Yes ❑No ❑Yes ❑No 4 Unknown <br /> Propertygq owner's mailing address if differenti than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 1 3 2 IN,€i,i;rTOSK1 LVD <br /> -f in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br />' SCREEN/OPEN HOLE <br /> WELL OWNER'S NAME/COMPANY NAME 86 <br /> Screen from to ft. Open Hole from to ft. <br /> DAVID BILLtit OBSTRUCTIONS <br /> Well owner'sr' mailing address if different than property owner's <br /> address indicated above A Rods/Drop Pipe ❑CheckgValve(s) y�❑Debrisi ❑Fill ❑No Obstruction <br /> 1729 l G,�w#�1ii. & POINT R DROP PIPE <br /> Type of Obstructions(Describe) <br /> ° O' )* MN 55391 <br /> Obstructions removed? 111 Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARQNESS OR FROM TO <br /> FORMATION ❑Not Present QPresent,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE <br /> Li RI P3 11 1 tit) METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> .F]No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> Casing 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 A No TN# <br /> GROUTING MATERIAL(S)NEAT�a CEMENT T 1 86 7 <br /> Grouting Material from to ft. yards ._ bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS i <br /> Other unsealed and unused well or boring on property? ❑Yes A No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 /> ..t. iA S O OLA WELL CO 1 b I <br /> Licensee Business Name License or Registration No. <br /> --2,/'-.5(, <br /> , <br /> 9/30/22 <br /> F/ - ir ' 558 <br /> Cerrtifiedihepresentative Signature Certified Rep.No. Date <br /> LOCAL COPY H g 6 98 g ,BERRY B R R <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />