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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring (r 1 . <br /> WELL OR BORING LOCATION Sealing No. H 3 c' 2 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> �t Minnesota Statutes,chapter 1031 or W-series No. <br /> Sad`ttt >4r';r (Leave blank if not known) <br /> r Township Name YF Township No. Range No. Section No. Fraction(sm.-w lg.) Date Sealed Date Well or Boring Constructed <br /> 0R(TO 117 2 05 SEES; ,/, 1/5/23 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 144 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 ❑Multiaquifer <br /> 33r0 + : , g]Measured Date Measured 1 I' 2 <br /> t WELL/BORING ❑Estimated <br /> ®Water-Supply Well Li Env.Well <br /> Show exact location of well or boring 55356 Sketch map of well op5oring 22 <br /> in section grid with"X" location,showing p�o perty ❑Temp.Boring ❑Other ft. IX below ❑above land surface <br /> lines,roads,a t5uildings. <br /> N ( s CASING TYPE(S) <br /> )( A Steel ❑Plastic ❑Tile ❑Other <br /> WELLHEAD COMPLETION <br /> w EI <br /> Outside: A Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> h Mile , ❑Well Pit ❑Buried ❑Well House <br /> - ---.- 1 .�..''''''') <br /> ❑Other ❑Well Pit <br /> s ❑Buried <br /> I——1 Mile { g -- »» � w` ) ❑Other <br /> f <br /> For temporary borings,provide additional locatio? CASING(S) . <br /> information,a site sketch,and geology on a separ ge. _Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME 4 4 in.from to ft. ❑Yes ❑No ❑Yes ❑No Unknown <br /> Li <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 /> SCREEWOPEN HOLE <br /> Screen from 136 to 144 <br /> ft. Open Hole from to ft. <br /> WELL OWNERS NAME/COMPANY NAME <br /> W I LLIJA `''RUBECk OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above g Rods/Drop Pipe ❑Check Valve(s) ['Debris ❑Fill ❑No Obstruction <br /> DROP PIPE <br /> Type of Obstructions(Describe) <br /> Obstructions removed? g Yes ❑No Describe <br /> PUMP <br /> HARDNESS OR <br /> GEOLOGICAL MATERIAL COLOR I FORMATION FROM TO ❑Not Present [X Present,Removed Prior to Sealing ❑Other <br /> If noty known,indicate estimated formation log from nearby well or boring. Type <br /> DRIFT F,#, SUBMERSIBLE <br /> 1 144 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) <br /> NEAT CEMENT 1 144 12 <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 /> ) <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 /> L.ON STu OLA WELL DRILLING CO• ,INC. 1 b91 a <br /> Licensee Business =me License or Registration No. <br /> ," 1/5/23 <br /> `Cert'red Representative'Signature . Certified Rep.No. Date <br /> JERRi BARB <br /> LOCAL COPY H ' Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />