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wELL Ort BORING LOCATiON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' <br /> County Name <br /> WELL AND BORING SEALING RECORD Minn'esota Unique Well No. <br /> ��Q�(�p3j1 Minnesota Statutes,Chapter 1031 or W-series No. <br /> tise�re de�n oa a�o«n> <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> Jrcmo I17 2 fl9 3 5'. ,. ,. .- <br /> GPS �a� degrees minutes seconds � <br /> LOCATION: Depth Before Sealing �� ft. Original Depth (t. <br /> Longitude degrees minutes seconds p FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ngle Aquifer ❑Multiaquifer <br /> WELUBORING �Aeasured ❑Estimated <br /> [�Vater Supply Well ❑Monit.Well i <br /> Show exad location of well or boring Sketch map of well or boring /�t <br /> in section grid wiTh'X' '�y location,showing property ❑Env.Bore Hole ❑Other �ft. [�elow ❑above land surface <br /> N �� lines,roads,and buildings� CASING TYPE(S) <br /> � <br /> -T- -T- -�-- -,-- �teel ❑Plastic ❑Tile ❑Other <br /> i <br /> W "f- 'Y' -1" "l" E ���� p WELLHEADCOMPLETION <br /> � Outside: ❑Well House Inside: ❑Basement Offset <br /> --�- -i-- -f- -f- <br /> �� �Pitless Adapter/Unit ❑Well Pit <br /> --�- -i-- -�-- -�-- � � <br /> � ; ❑Well Pit ❑Buried <br /> g \\ <br /> �—"^'�—�' �� ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � Diameter � Depth � Set in oversize hole? Annular space initially grouted? <br /> Properry owner's mailing ess it different than well location address indicated above �� <br /> "� in.ffOm�_ t0��ft. ❑Yes �No ❑Yes ❑No ❑Unknown �� <br /> 24(�l4 Veit Piace <br /> R���r$� t� 55374 i11.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> P � � in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> W LL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> r /�+�y � <br /> Well owner's mailing address it different ihan property owners address indicated above Screen from�t0�ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) .1 ua/f� �,£i�� � �U r�� <br /> GEOLOGICAL MA7ERIAL COLOR HARDNESS OR FROM 70 Obstructions removed? es ❑ No Describe <br /> FORMATION <br /> If not known,indicate esromated fortnation log from nearby well or borinq PUMP /� <br /> t�C�.f� � 77 TYPe .1 c.s.r. /` (.J�1(� <br /> �emoved ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ❑�lo Annular Space Exists ❑ Annular space grou[ed with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=SO lbs.) <br /> Grouting Material_�L�� ��r/��ofFi—s.C_to�ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 intormation contained in this report is <br /> true to the best of my knowledge. <br /> Tait#t�todc�Is �11 Dtiilis�; Co.. Inc. 27172 <br /> Contractor Business Name License or Registration No. <br /> '`�,��� r� ;�. r 11��T15 <br /> Authorized Representative Signature Date <br /> LOCAL COPY H �i�3��8 �j'�"1 `St�CI1�C <br /> ��'� ��. Name of Person Sealing Well or Boring <br />