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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 9 9 I ) <br /> SCounty Name WELL AND BORING SEALING RECORD M nnlesotaoUnique Well No. <br /> • Minnesota Statutes,chapter 1031 or W-series No. <br /> ;{ N�'w IJ$ 4`• p (Leave blank if"known) <br /> Township Name •F Township No. Range No. Section No. Fraction(sm.—,lg.) Date Sealed <br /> Date Well or Boring Constructed <br /> QIWNU 117 23 17 SW S*PI 4,14 12/2/f 2 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 117 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 X Single Aquifer ❑Multiaquifer19 �terr'''' ryr� p / <br /> �' s POINT r r LUBORING Li•+rneasured Date Measured 1 d.J 2 7/ 2 2 ❑Estimated <br /> :i:Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring',ii • 5 map of well or boring 54 <br /> in section grid with"X." ron,showing property ❑Temp.Boring ❑Other ft. ]below ❑above land surface <br /> roads,and buildings. <br /> N CASING TYPE(S) <br /> /gl Steel ❑Plastic ❑Tile ❑Other <br /> T ` ''' WELLHEAD COMPLETION <br /> W E 4 <br /> __�___. T__- T ., Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: A Basement Offset <br /> 'k Mile r ❑Well Pit ❑Buried ❑Well House <br /> I-- • ' . ❑Well Pit <br /> • s c,� ❑Other <br /> ❑Buried <br /> 1-1 Mile I ,, <br /> ...,,,'fir � ❑Other <br /> For temporary borings,provide additional location CASING(S) <br /> E° information,a site sketch,and geology on a separate page. Di eter De th + Set in oversize hole? Annular space initially grouted? <br /> P s�P► 1 t� �L Elp NAME in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Property owner's mailing address it 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 /> WELL OWNER'S NAME/COMPANY NAME Screen from 1 13 to 117 ft. Open Hole from to ft. <br /> SLAIN , P i .RSON OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above N Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) drop pipe <br /> • <br /> Obstructions removed? llrYes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Nat Present [Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type jet pump <br /> drift 0 117 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> X 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 No TN# <br /> GROUTING MATERIAL(S) Cement <br /> Grouting Material Neat from 1 to 1 1 7 ft. yards 5 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 r 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 /> DON ST D LA WELL DRILLING O. ,I C. 1691 <br /> Licensee Business Name License or Registration No. <br /> { . 12/28/22 <br /> Clhitifiecd Representative Signature Certified Rep.No. Date <br /> LOCAL COPY H 3 9 3 2 Jerry Barr <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />