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� <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I '� � '`�� � `� <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennle90 aoUnique Well No. ,,� �` <br /> Minnesota Statutes, Chapter 1031 or W-series No. <br /> �'enne in ��e�,ao�a�k,��a,k�ow�, <br />. Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> 4cono lI8 23 3& '� NF S"� /.�' <br /> GPS LOCATION- decimal degrees(to four decimal places) � <br /> Depth Before Sealing_ � ft. Original Depth_ ft. <br /> Latitude_________._ Longitude ----- <br /> �IFER(S) STATIC WATER LEVEL C�-� pF OR <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer I_j Multiaquifer �1 <br /> WELUBORING Measured ��Estimated Date Measured ,ri^�3L � � <br /> i�i C!�evq Bhase nc, �LOC14 55�91 - Water-Su I Well • <br /> � PP Y u Monit.Well �!7 <br /> Show exact location of well or boring Sketch map of well or boring � � - ,�( �t. �below 1-!above land surface � <br /> �. in section grid with"X" location,shqwing property Env.Bore Hole ��__;Other _ ,__ ; <br /> (� lines,roac�`+amd buildings. <br /> N � _.� .._�. ,r�.F�� CASINGTYPE(S) <br /> � <br /> .. --'--- --'--- ---`-- ---'- �' - <br /> � Steel ��Plastic '._Tile �_',Other ____ <br /> --'--- --'--- ---`- ---`- WELLHEAD COMPLETION <br /> = W ; : _ ; ET �-.--- <br /> .., __;_ _ _;_ ;_ _ �__ Outside: ��_J Well House �,_1 At Grade Inside: y�8asement Offset ` <br /> 'h Miie '�]Buried i._.i Well Pit <br /> � [�Pitless Adapter/Unit - <br /> j Buried <br /> ___j Weli Pit <br /> � , S f 1 I_I Other_ �� <br /> ' �i Mile� ,�yQ-� _]Other_ - � � ' <br /> t P^ROwPERTY OWNER'S NAME!COMPANY NAME CASING(S) <br /> t�tl�th ��� Dia eter Depth � Set in oversize hole? Annular space initialiy grouted? <br /> Prope.rty owners mailing address if different ihan well location address indicated above �� / --� - <br /> �_ in.from��� to l.� ft �j Yes �No [_'Yes [��No [;Unknown <br /> . __,_in.from to ft. �,_,'Yes �_ �.No I ;Yes � J No �]Unknown <br /> in.fram to _ft ❑Yes [I No � _Yes � ,No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � <br /> � , f <br /> � Well owner�s malling address If dltierent than property owner's address indicated above SCreen from1�� to�7_ ft. Open Hole ffOm to_ ft. <br /> OBSTRUCTIONS <br /> RodsiDrop Pipe [��Check Valve(s) I ,Debris ���Fi�l I 'No Obstruction <br /> i /�( " <br /> "- Type of Obstructions(Describe) ��n _�/�%.__¢ �� _ ' <br /> GEOLOGICAL MATERIAL COLOR HAHDNESS OR FROM TO Obstructions removed? �Yes I_i No Describe <br /> FORMATION - — - ——--- <br /> ; PUMP�„ ��: <br /> If not known,indicate estimated formation log from nearby well or boring. +�..�- �'l���— <br /> V ��C TYPe �,7 - � --------- — <br /> ���Removed i�i Not Present ���Other..__._ .. . _ <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists '� �Annular Space Grouted with Tremie Pipe ���I Casing Perforation/Removal <br /> - in.from to_ _ __ fL ��Perforated ���Removed �� <br /> in.from to_ ft. �_j Perforated � �Removed � � . <br /> Type of Perforator . <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? , �_Yes No TN#____,___ <br /> � GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> �}}► �r'� / f <br /> Grouting Material��/yL����� from_CL'_' to.��_ ft._._ _ __ yardsy� bags <br /> trom_,__ to_ ft. yards bags <br /> > --— -- trom -- to ---- ft,---- - Yards— --- bags <br /> OTHER WELLS AND BORINGS <br /> REMAHKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? I. :Yes � - No 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 /> 7 <br /> l�arn Stodol.a i�tel� �rillin�; Co,. In�c. 1b91 <br /> > — - — — —— - — __-- -- _- _ ---- _ <br /> Licensee Business Name � �-�� � License or Reg�stration No. <br /> ' / � .. <br /> " ._.�- i - ."`- <br /> , � <br /> ' - _ ._ .- .�'_--_. �-�_�-��. .-.._-.__. � <br /> �� Ce � rta tv � nalure;- .�� = -' Certilied Rep.No. Date ;. <br /> a �� ��Y .-.�,�t7'Yti <br /> ? LOCAL COPY --— — _._ — ---- -- -� --_ — i <br /> " 3 3 31�1 Name of Person Sealing Well or Boring ��^� <br /> HE-01434-14 IC#140-0423 5.��3R <br />