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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring `� �'� � � f�f"' ' WELL OR BORING LOCATION Sealing No. H �' .�_ "a.1�„! ,a'� � County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Cha ter 1031 or W-series No. qennein P ��ea�e b�a�k,��o,k,�ow�, Township Name Township No. Range No. Section No. Fraction(sm.--�Ig.) Date Sealed Date Well or Boring Construcied Ocono 117 23 08 1� �� :�; / �f C / = GPS LOCATION—decimal degrees(to four decimal places) / ; � Latitude _ Longitude Depth Betore Sealing__ ��__,_.__. fl. Original Depth __._ ft. " A UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location � Single Aquifer �Multiaquifer ��/ v WELLBORING I��easured �_'�Estimated Date Measured �RI'Y}� p/Q f 3�?9i� (:hPrry Ave, �rono ��Water-Supply Well U Monit.Well I Show exact location of well or boring ` Sk c well or boring , ^� �/ in section grid with"X" • location,sho ng property �.�Env.Bore Hole (J Other _`5 ft. I�below ❑above land surface N � �lines,roads, d buildings. CASINGTYPE(S) i r. • --'-----`-- --`-----'-- Steel �.J Plastic :�Tile ❑Other _ _ ' --'--- --'--- ---`-- ---�-- WELLHEADCOMPLETION + W ; ; ; ; ET -_ �__ _,____ � __;_ Outside: j]Well House ❑At Grade Inside: ��_�Basement Offset � , , , , /Miie � Ness A p r/Unit �Buried ❑Well Pit , , , , � �P' da te --;-- --;--- --�-- ---�- Well Pit ❑Buried -.. S ❑Other ., ____. _-- �1 Mile--{ r' � .�� ❑Other ___ ._�,l-'...>.�.1.. PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Jeff Ra�unz Diameter � Depth � Set in oversize hole? Annular space initially grouted? P�operty owner's mailing address if diflerent Ihan well location address indicated above �� /_� �_in.from__�_ to�ft. ❑Yes �No []Yes [_J No ❑Unknown 26(� �� I,afSyet Ce Rd r.a,niCe1��4�� 1�T SS33I in.from to ft ��Yes �__]No ��Yes ❑No ❑Unknown in.from to _fL �I ';Yes �]No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME,�COMPANY NAME SCREEWOPEN HOLE� ( - Well owner's maiiing address if different than property owner's address indicated above SCreen from C.N✓_ tp_ +'`� ft. Open Hole ffom to _ft. OBSTRUCTIONS Rods/Drop Pipe �J Check Valve�s) [�Debris ❑Fill [;No Obstruction Type of Obstructions(Describe��N`�` _�� 9' V'�/ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? '�,�'es ;�No Describe_ FORMATION PUMP �� If not known,� dicate estimated formation log from nearby well or boring. � I � �I� TYPe �,t' Removed ��vot Present ❑Other / \ METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists �Annular Space Grouted with Tremie Pipe L]Casing Perforation/Removal ��, ____ __in.from to __ ____ft. ��.'��Perforated ��.`;Removed ' �� _in.from_ .______ __.to __ fL �..I Perforated ❑Removed ' ; Type of Perforator ' VARIANCE Was a variance granted from the MDH for this well? ��_ ,Yes � ,No TN# _ _ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) - f1� M �}'' I '`/ x Grouting Materiai��I'�f/ �'"L N�(�om �` to,_._�v ft. _.. yards_ � bags from to___ ft. yards bags ' _ _ ______ from to ft. yards______ bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFPICULTIES IN SEALING Other unsealed and unused weil or boring on property? !�Yes �� o How many? LICENSED OR REGISTEfiED 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. �? il__Stt�clola We11 nri 11 i n� p� Tnr_ �� Licensee Business Name License or Registration No. "''? /�+`~"�,.e� � fri"'� f �- �.J f C�� resen ative Signature�'� Certified Rep.No. Date �r � r., �r � ?��:.. y �,� - LOCAL COPY H �'� � � 5 9 6 �`}'yv ~./4-.,a j : v_� Narne ol Person Sealing Well or 8oring� � . HE-01434-74 IC#140-0423 5n3R