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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �g 5 7 0 9 <br /> County Name WELL AND BORING SEALING RECORD Minnlego a�Unique Well No. <br /> ��N$p;� Minnesota Statutes,Chapter 103/ or W-series No. <br /> ��ea�e oia�k a�o�k�ow�� <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> BON 11� "�3� �9 N'` J/� � !U <br /> � <br /> GPS Latitude_ _ degrees minutes seconds Depth Before Sealing ��� ft. Original Depth ft. � <br /> - LOCATION: Longitude _ degrees __ minutes__ seconds AQ IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑MWtiaquifer <br /> • �.d• �j,"Qn� asi�• ��WG Measured []Estimated Date Measured� �' � � <br /> • upply Well ❑Monit.Well � <br /> Show exact location of well or boring Sketch map of well or boring i -��Env.Bore Hole Other � '__fl. below <br /> in section grid with"X:' �.--; location howing pro erty �- ❑ � ❑above land surface <br /> N lines,r s and b in s. CASING TYPE(S) <br /> ` --'--- -`-----`----'-- <br /> teel ❑Plastic ❑Tile ❑Other <br /> � '"''----'--- ---`-----`-- WELLHEAD COMPLETION � <br /> W ; ; ; ; ET _ <br /> �; __�_____,___ __;_____r__ Outside: ❑Well House �]At Grade Inside: ❑Basement Offset �' <br /> _� , , , � nniie PitlessAdapter/Unit �Buried ❑Well Pit <br /> h � • <br /> � --,--- --,--- --.-- ---:- 1 <br /> ❑Well Pit ❑Buried <br /> S ❑Other <br /> �1 Mile—� ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Dia.�mfeter /� � Depth � Set in oversize hole? Annular space initially grouted? - <br /> Property owner's mail t Ih tion address indicated above �! ��in.from i✓ to���ft. ❑Yes �No ❑Yes ❑No ❑Unknown ���` <br /> 15a050 23 =� ��� i� in.from to ft. ❑Yes �.]No ❑Yes ❑No ❑Unknown <br /> Plyaouth, l�N.. 55447 <br /> in.from to ft. ❑Yes [�No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � <br /> : � � <br /> x Well owner's mailing address if different than property owner's address indicated above Scfeen frOm���to��__ft. Open Hole ffom to ft. <br /> OBSTRUCTIONS - <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> 2 HARDNESS OR Obsiructions removed? <br /> GEOLOGICAL MATERIAL COLOR FORMATION FROM TO ❑Yes ❑No Describe <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> Type <br /> ❑Removed �Not Present ❑Other <br /> METHOD USEO TO SEAL ANNULAR SPACE BETWEEN 2 CAStNGS,OR CASING AND BORE HOLE: <br /> � No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. []Perforated ❑Removed <br /> in.from to R [)Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material �+�/+�� ���.��.,6(om�_ to�� ftr yards �' bags <br /> trom to ft. yards bags <br /> from to ft. 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 o 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 <br /> is true to the best of my knowledge. <br /> ` DON STOD�LI► WEI.I. t�ittT.r.INO C0.-, �I�I�. ,an, , <br /> L�censee Business Name �....._ '.„_. y„-. L�cense or Reg� r �n o. <br /> / <br /> �-- � 558 —/S'- /O' <br /> C �fi reS ntative Signature � Certified Rep.No. Date <br /> � . �...,.., <br /> LOCAL COPY H �}(��O 4 Name ol Person Sealing Well or Boring r <br /> ; y J <br /> HE-01434-11 IC#140-0423 - 2ioaa <br />