2008 Well & Boring Sealing Record

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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' �(t��Z County Name WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No. ,i, � � Minnesota Statutes,Chapter 1031 or W-series No. , (LeavB blank i�no�known) T Township Name Township No. Range No. Section No. Fraction(sm.�IgJ Date Sealed Date Well or Boring Constructed Ororro lI7 23 21 20'' '' �'f_� U'"� ' � i, GPS - Latitude degrees minutes seconds Depth Before Sealing G.i� ft. Original Depth ft. LOCATION: Longitude degrees minutes seconds AQ IFER(S) STATIC WATER LEVEL �c. Numerical Street Address or Fire Number and City of Well or Boring Location _Single Aquifer ❑MuRiaquifer �+ /� (� !�� 2500 Casco Point Rd, tIC� 5�'f��, WELL/BORING �Measured ❑Estimated DateMeasuredJ�///� '/� Water-Supply Well jJ MoniL Well ��. Show exact location of well or boring Sketch map of well or boring — ` . in section grid with"X" location,showing property —;Env.Bore Hole ❑Other �J� __ft ,�below ❑above land surface �I�' lines,ro�ds, nd buiMin s. !' N , , . � ..�y„� ..,�:;� CASING TYPE(S) � , � �,�-, ..�i � � ` _ . �_ � .__ � � +: '� , �YSteel ❑Plastic ❑Tile ❑Other : , , 7'7'� -- ' --�-----'--- ---`-- ---`-- WELLHEAD COMPLETION : W ; ; ; � ET , �� , ' r r Pitless Adapter/Unit � _ ____ __ __ __ __ __ Outside: ' Well House At Grade Inside: ❑Basement Offset p� :; , , , , Mile �Buried ❑Well Pit 'h � 1tY : ' ' ; � `t\ is --'-----T-- --•-- --�- ❑Buried r S �;]Well Pit �t Miie—� ❑Other ❑Other PR PERTY OWNER'S NAME/COMPANY NAME ��. CASING(S) �; �� r . P$u�$ �J Diam te�� r Depth�/� r Set in oversize hole? Annular space initially grouted? �� Property owner's mailing atldress if different than well location address indicated above �in.ffom� lo�.((i_ft. n Yes I�No L]Yes �]No ❑Unknown t � . in.from to ft r]Yes ',� ;No ❑Yes ❑No ❑Unknown in.from to ft [ �Yes `]No ��Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � � Well owner's mailing address if ditterent than property owner's address indicated above SCreen ffom__�to �� ft. Open Hole ffom to ft. OBSTRUCTIONS Rods/Drop Pipe ❑Check Valve(s) r 1 Debris ��Fill ❑No Obstruction Type of Obstructions(Describe) � N� � _.1- �I= g" �(,��Q ____ GEOLOGICAL MATERIAL COLOR HARONESS OR FROM TO Obstructions removed? �Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. ��p �}�m ^ Type C /� /l ��-� f-" �", -�� Removed ❑Not Present U Other ___ _ � METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �Vo Annular Space Exists I_I Annular Space Grouted with Tremie Pipe U 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.) /� v1y�� '' /� I / � /Q Grouting MaterialN L/YT CL/��'V�from �/ to��`=' ft. yards� bags from to ft. yards bags _ from to R. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN 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. Don 5tc�dnl� iL►11 flri��A. T�..�_��e�r L�censee Busin ss me ��'is�c ense or RegistraGon No. s �/` -'`'w '-�� c�;' � � er ' epresentative Signature� Certified Rep.No. Date t_"v:)l\L CO7Y H i.��T V V Z �' y� �� J....0 ..._. Name ol Person Sealing Well or Bor�g ^ HE-01434 10 IC#140-0423 . sio�a� .. , ,.. . ....,. . ... _ __.. .... . , n. _ � . . . ,.. ..... . _ . .. . , _ - .....e> ,...t_ .,.___.». . .._.. ,