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. � . -.�, � <br /> _ :� , .. . . <br />� ;� =�.=, <br />'�" wE�L OR BORING LOCA'nON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I <br />�` WELLAND BORING SEALING RECORD Mnn'esotaUniqueWeltNo. �� 8 <br /> County Name <br /> F��LtEtta��t1 Minnesota Statutes,Chapter 1031 or W-series No. <br /> . t�u�a�a a�� <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> rar�, i t� 2 3 l h 22-C?�Q2 .,. <br /> ZZ- .;�,�(' t� <br /> GPS <br /> Latitude degrees minules seconds f� � <br /> LOCATION: Depth Before Sealing /� ft. Original Depth ft. <br /> " Longitude degrees minutes seconds qpUIFER(S) STA71C WATER LEVEL <br /> ��� ��Numerical St�eetAddress or Fire Number and City of Well or Bonng Location Single Aquifer ❑Multiaquifer <br />�e: f� �Measured ❑Estimated <br /> 1�7�4� �Q�� PQ��t �t�� �r�II(,� 55391 WELUBORING ! <br /> �Water Supply Well ❑Monit.Well <br />�.-� Show exaC[IocaGon of well or bonng ��Sketch map of well or bonng t�� �,,( <br />�•_ Env.Bore Hole ❑Other ft. below above land surface <br /> in sechon grid with"X" location,showing property ❑ A�l ❑ <br />�;;;;�, . N lines,roads,and buildings. � CASING TYPE(S) � <br />.�-.�','_'.'�- . <br />� - - - - - -- ' -- <br />''� � �Steel ❑Plastic ❑Tile ❑Other <br />'�e. . � �: - -- � . <br /> . W —�- --i— E WELLHEAD COMPLETION <br />�. , ' � � �{ Outside: ❑Well House Inside: ❑Basement Offset <br />'�—.. � � I - <br />'= � --r- �-i'- -i— --�-- .. <br />�` <br />��'i; 1��e ❑Pitless Adapter/Unit ❑Well Pft <br />;�.r.. - - -�-- -i-- --�-- I <br />�. - <br />�:.�.-�� 1 ❑Well Pit �uried <br />�:• S �J"" <br />�;':.... 4'—i""i°—+�. �Buried <br /> I I <br />�' PROtP,,E,�RTY OWNE,R.,'Si NAME/COMPANY NAME CASING(S) <br />�y' �LJC�� CCa1 � �L�e$ Diameter � Depth � Set in oversize hole? Annular space inRially grouted? <br />'� - Property owner's mailing address if diiterent than well location address indicated above �� .�.���_ <br />� � in.f�Om d t0�ft. ❑Yes ID+fJo ❑Yes ❑No ❑Unknown <br />�; Sb5 �3ig t�ods Blvcl •, <br />�' In.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br />�" aen, MN 55317 <br /> in.f�om to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE ! <br /> � <br /> Well owner's mailing address it dilferent ttian 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 /> �, <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO ObstrUctions removed? ❑YeS ❑ NO DeSCribe <br /> FORMATION <br /> tl not known,indicate estimated tormalion log from nearby well or boring PUMP <br /> Cfft Q � Type <br /> ❑ Removed ot Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists ❑ Annular space grouted wfth tremie pipe ❑ Casing PerforatioNRemoval <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=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> ^��{-y / <br /> Grouting Material ���� ('=/���T from Q to �/ ft. yards � bags <br />{ <br /> f 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 wetl 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 information contained in this report is <br /> true to the best oi my knowledge_ <br /> � <br /> Contractor Business Name License or egistration No. <br /> , <br /> Au e e resentative gnatu Date ���� <br /> LOCALCOPY <br /> H �a�o��o J� �t�� <br /> Name of Person Sealing Well or Boring <br />