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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„I <br /> Counry Name <br /> WELL AND BORING SEALING RECORD M nnle ota Unique Well No. <br /> �nne� in Minnesota Sfatutes,Chapter 1031 or W-series No. <br /> (Leave 04nk ii�krwwn) <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> t�rono � 7 23 20 3-tj(� �,. �,. ,. � <br /> GPS ��� degrees minutes seconds ���� / <br /> LOCATION: Depth Before Sealing---���+¢-t ft. Onginal Depth tt. <br /> Longitude degrees minutes seconds pQU1FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaqu'rfer <br /> C 1 Or S3 1 WELUBORING �(Aeasured ❑Estimated <br /> /' <br /> �Water Supply Well ❑Mond.Well <br /> Show exact location of well or boring � Sketch map of well or boring <br /> in section grid with'X" N ._.�---focation,showing property ❑Env.Bore Hole ❑Other ft. �Q below ❑above land suAace <br /> lines,roads,and buildings. � � <br /> N CASING TYPE(S) <br /> - - - - - -- -i-- <br /> �� Steel ❑Plastic ❑Tile ❑Other <br /> W --�- - - - — --i-- E �� WELLHEAD COMPLETION <br /> � � � � __ <br /> • Outside: ❑Well House Inside: ❑Basement Offset <br /> —�- ---- -;-- -i-- <br /> 1��b ❑Pitless AdaptedUnit ❑Well Pit <br /> --;- -�-- -�-- --i— I . <br /> 1 �Well Pit ❑Buried <br /> S <br /> �—�'"M�. ;. ,+,.<:,. '..f. �7� ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter Depth � Set in oversize hole? Annular space initlally grouled? <br /> P in � re�t than well location address indicated above �� � <br /> � in.f�om� t0��ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> C�OSCBVC' I?C�C�t3k3ri W� $�!X <br /> 4367 Shorelicze nC in.from to ft. ❑ves ❑No ❑ves ❑No ❑Ummown <br /> ��C�T]� P$C�E� � ��}3�1 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> W L N MPANY NAME SCREEWOPEN HOLE <br /> / � <br /> ���.'.�• '/�� <br /> Well owner's mailing address if ditterent than property owner's 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)�At1L<� f.�p` g V.< J <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Y2S ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> TYPe `-} ��" i_"L'!�'1�] <br /> �' ''�" `� �Removed ❑ 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 grouted with tremie pipe ❑ Casing PeAoration/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=94 Ibs.,one bag of bentonRe=50 Ibs.) <br /> /� /��� i �,+�� � <br /> Grouting Material!�'Gq T (,.:.[/��m�to�ft. yards � bags <br /> from to R. yards bags <br /> from to R. 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 information contained in this report is <br /> true to the best of my knowledge. <br /> T�i �t13dc�I� �e13 ntll.ir�CD,. Inc. 2717� <br /> Contracror Business Name . License or Registra6on No. <br /> _ �- /i ,a C� <br /> epr'e ative i ture Date <br /> ,r'' � <br /> LOCAL COPY H �"7�'7�./O �~ t _ " �t.., i �v ..�,d`r...✓ <br /> Name ol Person Sealing Well or Boring <br /> , 1 <br />