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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 2 6 4 3 2 WELL OR BORING LOCATION Sealing No. H ' Counry Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. �� � i� Minnesota Statutes,Cha/�ter 1031 or W-series No. ' Y (Leeve blank�it not known) Township Name Township No. Range No. Section No. Fraction(sm.-+IgJ Date Sealed Date Well or Boring Constructed g 4t�11O �� ! � � / f t� / GPS Latitude __ degrees minutes seconds Depth Before Sealing �/ ft. Original Depth ft. LOCATION: Longitude degrees minutes . seconds Q IFER(S) STATIC WATER LEVEL - Numericat Street Address or Fire Number and Ciry of Well or Boring Location Single Aquifer ❑Multiaquifer ��y!?�.. 1595 Bohr� P�int Rd, VCV[AJ �✓ELL/BORING �vleasured �_�Estimated Date Measured�1"�•-,- �� - Water-Supply Well ❑Monit.Well ....{�y/�� _ Show exact location of well or boring Sketch map of well or oring ;J Env.Bore Hole ❑Other J� ft. [�elow ` t in section grid with"X" location,showing pro rty i ;above land surface E N `` lines,roads,and buil 95� �CASINGTYPE(S) "� _''"' ___ ` _�_ �Y i ` � .,� `j,��. � J [_]Tile ❑Other � � � �., ��Steel . Plastic -- --- -- � WELLHEAD COMPLETION �`� W � � � ; E T � utside: f� ell House r]At Grade Inside: �;Basement Offset ^ --;-----�-- --�-- --�-- ` O ' W � �i+ �;. ; , ; ; nniie itless A pter/Unit � uned _ ell Pit ,� �P ; , , � da , g r]W --;--- --.-- --.-- -:-- l 0 � . ❑Buried � _ [;Well Pit ❑Other �1 Mile� � , �;Othef __ 7 , PROPERTY OWNER'S NAME/COMf,�PA,N�Y.,.N,,A.ME CASING(S) ' Robert Crai iAJ[t�Gi7 Diam te�� Depth � Set in oversize hole? Annular space initially grouted? , Property owner's mailing address if different than well location address indicated above �in.from � to�j,�ft. ❑Yes DQ NO ❑Yes ❑No ❑Unknown �1�4 Zti(� St� �@ ��. �� ��8jOr' �* ��t in.from to ft. ❑Yes ❑No ❑Yes [�No ❑Unknown Z i7P 1 in.from to ft. �,�Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE / I ► Well owner's mailing address if diNerent than property owners address indicated above SCfeen ffOm_��_to�_�ft. Open Hole from to ft. OBSTRUCTIONS Rods/Drop Pipe J Check Valve(s) �]Debris ❑Fill ❑No Obstruction - - Type of Obstructions(Describe)1/t1/L/�+�� a �u !.7 GEOLOGICAL MATERIAL COLOH HARDNESS OR FROM TO Obstructions removed? es ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. � . Type �L r'�.��1 M� <_� / t� ��/ � L�Fiemoved '�. �Not Pres nt Other )C ; METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: - � o Annular Space Exists I_J Annular Space Grouted with Tremie Pipe �]Casing Perforation/Removal in.from to__ ft. �]Perforated �]Removed in.from � to ft. ❑Perforated ❑Removed Type of Perforator �� ]Other �,�,��' GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) $, � r '�! Grouting Material �iQ%c`.�/�i�Yl/ from_�,� ro� ft. yards�_ bags - Y!. 1 from to ft. yards bags from to ft. yards bags - OTHER WELLS AND BORINGS �� REMARKS,SOURCE OP DATA,DIFFICULTIES IN SEALING �� Other unsealed and unused well or boring on property? ❑Yes o How many? ,�:i LICENSED OR REGISTEflED CONTRACTOR CERTIFICATION � This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. `' !ES We11 & p�� In Ibn Stodo2a i�ie11 �i.�.ling G�o di�i c on 1�1 ��,j Licensee Business ame � License or Registration No. � I - i � � � /� G � �Y . � r d`epre ntative Sighat e ` Certified Rep.No. Date � "'� .ccti�c.o�v H '�'t-'t,Ev.. �� /�}- .✓'.,�,�Y�..� 2 6 4 3 2 5 Name ol Person Sealing Well or Boring ;' HE-01434-10 IC#140-0423 . . 5/a7a ��