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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' . <br /> . <br /> SealinCounty Name WELL AND BORING SEALING RECORD MinnesotaeUnique Well No. [� <br /> t Minnesota Statutes,chapter 1031 or W;a eries No. <br /> hEANTownship Name Township No. Range No. Section No. Fraction(sm.— lg.) Date Sealed Date Well or Boring Constructed <br /> RO O 117 23 00 6 S ISE"4 9f 30, 21. <br /> GPS LOCATION—decimal degrees(to four decimal places) �1:i 2 0 <br /> Depth at Time of Sealing 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 ®Single Aquifer ❑Multiaquifer /� }i,. <br /> 775 LAK 1 V I L PARKWAY, R O, =,yX/4 WELL/BORING [ Measured Date Measured J i ' ❑Estimated <br /> I. [Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring .7.) Sketch map of well or boring t <br /> in section grid with"X." location,showing property ❑Temp.Boring ❑Other 5- ft. ®below ❑above land surface <br /> lines,roads,and buildings. <br /> CASING TYPE(S) <br /> - . '_ ❑Steel ®Plastic ❑Tile ❑Other <br /> i <br /> "-'1-------,-- WELLHEAD COMPLETION <br /> W ETOutside: Q Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> ❑Well Pit ❑Buried ❑Well House <br /> __________1 <br /> ❑Other ❑Well Pit <br /> S ❑Buried <br /> 1 Mile <br /> ❑Other <br /> For temporary borings,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. Dia13neter , , Depth Set in oversize hole? Annular space initially grouted? <br /> PRorpFvoyogR'S NAME/COMPANY NAME in.from to ft. ❑Yes ❑No ❑Yes ❑No [Unknown <br /> Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEN/OPEN HOLE <br /> 116 126 <br /> !)1E/C,CIf�i�t,El P, E Screen from to ft. Open Hole from to ft. <br /> WE L <br /> ai r OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill A No Obstruction <br /> Type of Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑No Describe ' <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION [ Not Present ❑Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type <br /> DRIFT 1 126 USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> A 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 I No TN# <br /> GROUTING MATERIAL(S) <br /> NEAT AT CE.AINT 1 126 11 <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 <br /> Other unsealed and unused well or boring on property? ❑Yes [ 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 /> ie$1. LE DUN S'r . OIJA WELL COT O 91 <br /> Licensee Buesy Name License or Registration No. <br /> -Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY H Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />