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wELL OR BORING L�CATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 1816 9 <br /> Counry Name <br /> WELL AND BORING SEALING RECORD MinrliesoNa Unique Well No. <br /> �tH1�P�.t1 Minnesota Statutes,Chapter f031 or W-series No. <br /> (Loave blank ii no�known� <br /> Township Name Township No. Range No. Section No. Fraction(sm-s Ig) Date Sealed Date Well or Boring Constructed <br /> ��° i 28 3 3 41 I2 ,� ,� �, <br /> 2 <br /> GPS Latitude degrees minutes seconds � Q/ / <br /> LOCATION: Depth Before Sealing ft. Original Depth—__��.___ ft. <br /> �ongitude degrees minutes seconds p FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer �( <br /> WELUBORING I/'�Measured ❑Estima[ed <br /> 7 <br /> �Water Supply Well ❑Monit.Well �� / <br /> Show exact location o well or boring Sketch map of well or boring � <br /> in section grid with"X" -, location showing pro�erty Env.Bore Hole ❑Other ft �below ❑above land surface <br /> lines,ro�ds,an�l buildin�. <br /> N �<� �� "� CASING TYPE(S) <br /> ..�! <br /> -�- -�— --�-- --�-- � <br /> Steel ❑Plastic ❑Tile ❑Other <br /> W —�- -- - — -- — E �y,''• WELLHEAD COMPLETION <br /> � , , , � t + Outside: ❑Well House Inside:�asement Oftset �, <br /> ---- -�-- -;— --�-- � <br /> �^��� � ❑ Pitless AdaptedUnit ❑Well Pit <br /> ---- -i— -�— --i-- I <br /> � ❑Well Pit ❑Buried <br /> S <br /> �—r'"n°---�' ` ❑Buried <br /> PROyP�,E,RTY OWNERT'S NAME/COMAPANY NAME CASING(S) <br /> i'N��t� �7�� 752-473-3773 Diameter Depth f Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above �1 <br /> � in.f�Om� t0�.,ft. ❑Yes �o ❑Yes ❑No ❑Unknown <br /> in.f�om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE 's <br /> � � <br /> Well owner's mailing address if diNereni than property owner's address indicated above Screen from t0 ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe)���fl' �1���T <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 2S ❑ NO Describe- <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring P�MP .. <br /> �,� • � � ' TyPe �� f �U� <br /> '`^^�'� `�� `�� �Removed ❑ Not Present ❑Other ` <br /> i. METHOD USED TO SEAL ANNULAR SPACE BE�:TWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �o Anrular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ 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 /> w � /y� /j / <br /> Grouting Material%v��� ��/"`��L to�ft. yards bags <br /> _from to ft. yards bags <br /> � . - _from to tt. 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 No How many? <br /> LICENSED OR REGISTERED CONTRACTOR-GERTIFICATION� " � � <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The�information contained in this report is <br /> true to the best of my knowledge. <br /> Don Stotio�a Well Dcilling Co , Inc 27I72 <br /> Contractor Business Name License or Registration No- <br /> - - � ._� �/ .:i y` <br /> esen ive Signature Date <br /> LOCAL COPY H ��H i�� � J"--' �"�^"�s�Y� <br /> Name ol Person Sealin g Wel!"o'Borin g� t <br />