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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � �"�� County Name WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No. � Minnesota Statutes,Cha ter 103i or W-series No. '�E'fd21P°')J Tl P �ea�e e�a�k,,�o�k�ow�� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sea�ed Date Well or Boring Constructed Or�no 117 ?3 2�1 S�? "'�' �K+� �1 T 1 j GPS LOCATION— decimal degrees(to four decimal places) 1 n ! Depth Before Sealing__ 1�,> ` .__.__ft. Original Depth_________ft. Latitude . Longitude __ ,�yg�IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ��tiingle Aquifer �'��Multiaquifer .� ..�R,�� V [� WELUBORING [�leasured ��,__i Estimated Date Measured_��" �. ��! � �nl� ('�sco ?'r�3�t �'�, �r��o 553�1 " �Water-Supply Well jJ Monit.Well �/� � Show exact location of well or boring Sketch map of well or boring -- in section grid wiih"X° location,showing property Env.Bore Hole ❑Other ft. �below [;above land surface N lines,roads,and buildings. CASINGTYPE(S) � --'-- --y----`-- --'— � ��„ Steel ��Plastic �Tile ❑Other ' '-'- ' `' `-- � WELLHEAD COMPLETION W � � � E �� _�. �. � ,__ T �, e� Outside: �Well House i_]At Grade Inside. ��Basement Offset � 'h n�tiie � � �pitless Adapter/Unit ❑Buried ��Well Pit a --,-- --,-- --.-- --: 1 d ❑Well Pit '�_�Burie S e ❑Other F-1 Mile-�� " L �� ❑Othef ______ x r _». �� PROPERT�OWNER'S NAME/COMPANY NAME CASING(S) F�ra Stannt�c� Dia ter� � Depth � Set in oversize hole? Annular space initially grouted? Properry owner's mailing address if different than well location address indicated above �� in.from� to �� ft. ❑Yes �lo ❑Yes ❑No �Unknown in.trom_ to ft. �Yes "I No ❑Yes ❑No ❑Unknown _ in.hom_ to R ��Yes �No ❑Yes ❑No (�Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE t ' �� Well owner's mailing address if different than property owner's address indicated above Screen from �� to �� ft. Open Hole from to tL � OBSTRUCTIONS ,�Rods/Drop Pipe ❑Check Valve(s) ❑Debris `_,�Fill ❑No Obstruction � /_�,�y� � ...r Type of Obsiructions(Describe) t��'✓f:f< /��- 4 �� _. __ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? I'�es ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. . TyPe �/� -�,�- �5 � � - �emoved `'�Not resent []Other ,_ ___ METHOD USEDTO SEAL ANNUTAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE: �.(Jo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe U Casing Perforation/Removal in.from to __ ft. ❑Perforated ❑Removed - ____,_in.from to_ ft ❑Perforated I]Removed :�� Type of Perforator__ VARIANCE Was a variance granted from the MDH for this well? i,^Yes o TN# �• GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) y� / / � GroutingMaterial N<AT��(//f� m � to f �} ft._ yards � bags s� from to ft. _ yards bags �;: ---- ---.._ :� from to ft. yards _ bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES W SEALING Other unsealed and unused well or boring on property? �,_J Yes � No How many?____ LICENSED Ofi 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 ihe best of my knowledge. non cta�t�la tdell Dcilliri�; Co,. Inc. 26�31 Licensee Business(Y2me � . License or Registration No. ' �.� �� � �� = �� ,,� 11-5—I4 , .,� ��rtifi�eed Representative Signature Certified Rep.No. Date . LOCAL COPY H � �4� 3� 9 9 Jim Antonson - ------------ Name of Person Sealin Well or Borin - HE-01434-14 IC#140-0423 sn3a 3