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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 413688 <br />WELL OR BORING LOCATIONSealing <br />WELL AND BORING SEALING RECORD Minnesotta Unique Well No. <br />County Name <br />HEN NE PI NY Minnesota Statutes, chapter 1031 orr„ -series No, <br />Township Name Township No, Range No. Section No. lFraction (sm. - Ig.) Date Sealed Date Well or Boring Constructed <br />OR0110 117 23 10 4d`P WNW '� 11/12/24 <br />GPS LOCATION — decimal degrees (to four decimal places) <br />Depth at Time of Sealing 67 it. Original Depth ft. <br />Latitude Longitude <br />AQUIFERS) STATIC WATER LEVEL <br />Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑ Multiaquifer ( i / 1 ry / 2 <br />660 BROWN E� . a • W i �+ ! . WELUBORING �] Measured Date Measured ! i G ❑Estimated <br />Q Water -Supply Well ❑ Env. Well <br />Show exact location ottw I r' ing Sketch map of well or boring <br />in section grid with "X- location, showing property ❑Temp, Boring ❑Other t( ff. ]below ❑above land surface <br />N lines, roads, and buildings. CASING TYPE(S) <br />W <br />E <br />Steel ❑ Plastic ❑ Tile ❑ Other <br />WELLHEAD COMPLETION <br />T <br />Outside: ❑ Pitiless Adapter/Unit ❑ At Grade Inside: Basement Offset <br />'h Mile ❑ Well Pit ❑ Buried <br />El Other Well House <br />❑ Well Pit <br />1 <br />s ❑Buried <br />)-1 Mile Other <br />For temporary borings, provide additional location CASING(S) <br />Information, a site sketch, and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially grouted? <br />Pf;pgE€4TY pWWER' iy CgMPANY NAME 4 in. from 1 to n 5 7 ft. El Yes ❑ No El Yes El No 1Z] Unknown <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 />SCR EE WOPEN rHHOLLE <br />Screen from .7 7 to f�ft. Open Hole from io tt. <br />WELL OWNER'S NAME/COMPANY NAME <br />}O�BSTRUCTIONS <br />Well owner's mailing address if different than property owner's address Indicated above u Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ FIII ❑ No Obstruction <br />Type of Obstructions (Describe) d Cb p pipe <br />Obstructions removed? ® Yes ❑ No Describe <br />PUMP <br />GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present CJ Present, Removed Prior to Sealing ❑ Other <br />FORMATION ❑ <br />If not known, indicate estimated formation log from nearby well or boring. Type ubme r s i b 1 e <br />drift 1 67 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />n 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 1P No TN# <br />GROUTING MATERIAL(S) tt <br />Grouting Material neat CemF nt from .! to (7 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 K] No How many? <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 />1)0iN `,T')DO A '01:1,1T ngu jjT4 -c-4 , i_N 16�I <br />Licensee Buslne Name — Licens!? or Registration No. <br />1691 11/20 247, <br />Certified Representative Signature Certified Rep. No. Date <br />.Jerry Ilarr <br />LOCAL COPY H 413688 Name of Person Sealing Well or Boring <br />H E-01434.17 ID# 53159 1 f /1 sR <br />