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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OP HEALTH Minnesota Well and Boring '„I ��]�/� �� County Name WELL AND BORING SEALING RECORD Menneso a�Unique Well No. � �� ��ay) Minnesota Statutes,Cha ter f03/ or W-series No. i p i D p fLeave blenk il nol known) - Township Name Township No. Range No.Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Osono 117 23 20 I�tSE 9i /2 _� Q� _ y/�1 � � GPS Latitude degrees_ ..__ minutes_ seconds Depth Before Sealing /� ft. Original Depth ft. � LOCATION: Longitude _ degrees____,_ minutes_ seconds - � � —— �ER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location gle Aquifer ❑MWtiaquifer �tl�F p v'1 i 2623 Casec p��nti �� OrOQ��. �• W�EI B�RING Measured ❑Estimated Date Measured i' r�� � �4�/ater-Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or boring �Env.Bore Hole ,�/ � in section grid with"X." �5�� n,showing e �-� ❑Other �R. �'below ❑above land surface N �lin d a �n� CASING TYPE(S) ----- -' _ _ _ - � �eel ❑Plastic ❑Tile ❑Other p ' ' ' ' ' " "`' " '" WELLHEAD COMPLETION � W ; ; ; ; ET ,y1 ,. : _� � � � � �v Outside: ❑Well House [j At Grade Inside: ❑Basement Offset �: 'h Mile ❑Pitless Adapter/Unit ❑Buried ❑Well Pit �� -;---�--- ---;-- --�- I ❑Buried L [�ell Pit S ❑Other �t Mile—� ❑Other PFOPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diamete� � � Depth t Set in oversize hole? Annular space initially grouted? Property owner's mailing a ress if i eren t an well loca ion a re s in icated above ^� �in.from � to__�G�ft. ❑Yes [�lo ❑Yes ❑No ❑Unknown �8te as a�� in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown f 952-401-3410 ` in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown � r WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � � � � Well owner's mailing address if different than property owner's address indicated above Screen from !� to_,�"" R. Open Hole from to ft. OBSTRUCTIONS . . � , � - �ods/Drop Pipe ❑Check Valve(s) ❑Debris� .��J Fill ❑No Obstruction �,... . ..�- Type of Obshuctions(Describe) ��l�l�� r/'f � �� GEOLOGICAL MATERIAL COLOR HaeoNEss oa FROM TO Obstructions removed? es �-��No Describe FORMATION - PUMP If not known,indicate estimated formation log from nearby well or boring. / �� � ��T��Y��..��P..e/ `.+��__ . j�emoved (�Not Present ❑Other __ _______ METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: i�o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to R. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed a Type of Perforator ❑Other. ---_.._-- — -� GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) L/� /� � C�/_ � /- Grouting Material �..�l7/ C�-/��.(l om_�P _ to _ ��7 ft. yards �/ bags from to ft. yards______ bags from _ to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING . . Other unsealed and unused well or boring on property? '_Yes � o 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 3TOM?Ll� i�ISLL DBILLII�G C0. • INC. 1691 ; _ _ _--- ---- --_ — ---- Licensee Business Na e License or Registration No. - gs8 /� I� vc� _ - - - -_ ___ __ ; rti/i R resen ative Signature � � Certified Rep.No. Date H 27549?{ -��r� ' LOCAL CCPY I Name ol Person Sealing Well or Boring = --------....__._._---- �- HE-01434-11 IC#140-0423 2ioaa