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i _ _ _ _ _ _ _ _ : MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring� �� WELL OR BORING LOCATIO�I Sealing No. H .s County Name � WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Chapter 103I or W-series No. Neime in «ea�e b�a�k,,�o,k�w�, Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed 117 23 I6 N�f I� N'�I !a " �� GPS Latitude.. . degrees___ minutes_____ seconds Depth Before Sealing ��J / ft. Original Depth fL , ` LOCATION: Longitude_____ degrees_ minutes______ seconds � FER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and Ciry of Well or Boring Location '�� ingle Aquifer ❑Multiaquifer 172� DVi[iJ� cVj�t Rd Ot� BORING �Measured ❑Estimated Date Measured ��'K s I�ter-Supply Well ❑Monit Well � Show exact location of well or boring Sketch map of well or boring in section grid with"X." '� location,showing property n Env.Bore Hole ❑Other _�� ft. �below ❑above land surface N ;lk lines,roads,and buildings. CASING TYPE(S) 7l I I I ' .. t� ��: --'-----y-- ---`-- ---'-- � V� i�teel ❑Plastic ❑Tile �Other --'--"'"�'"" ``-- --'`-" WELLHEAD COMPLETION ` � W ; � ; ; ET __;____,___ __;__ __;__ Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset z 'h M'ie ' � �Pitless Adapter/Unit ❑Buried ❑Well Pit - - - l �� �� ❑Buried . '�� []Well Pit S ❑Other �1 Mile� ❑Other � PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) � Diam�t �( ` j � 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_�ft. ❑Yes �lo ❑Yes ❑No ��,I Unknown 2'tV7 VC7CI1 SC R in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown Richfield, 1�I 55423 f ., �} in.from to ft. ❑Yes � No x ] I,]Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � Well owner's mailing address if different than property owner's address indicated above SCfeen ffom �(� to��ft. Open HOIe ffom to ft. OBSTRUCTIONS I�Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fili ❑No Obstruction Type of Obstructions(Describe)^��'�� i""'-" � �/`>'�t� __ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ( �1'es ❑No Describe FORMATION — PUMP If not known,indicate estimated formation log from nearby well or boring. � j"� drift O �p Ty e �V� Y Fl�? n � �emoved j�Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: [�{p Annular Space Exists ❑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 i GROUTING MATERIAL(S) (One bag of cement=94 Ib�.,one bag of bentonite=50 Ibs.) y�/ ^ I Grouting Material'�� /�/�rU -/from � to f GJ ft. yards� bags from to _ ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES W SEALING Other unsealed and unused well or boring on property? ❑Yes�No How many?_ LICENSED OR REGISTERED 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. Licensee Business Name � ��or Registration No. ' TG7� _ . —. ._--- — ._.___.__ : rt� e resen a ve Sig� re Certified Rep.No. Date -; H 279247 '�° �`°`�°� ` LOCAL COPY ----- — — ----- _ Name ol Person Sealing Well or Boring ----- ____.-------------- — HE-01434-11 IC#140-0423 2/OBR Ii