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ELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H j ��9 7 8 <br /> � :ounty Name <br /> WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No. <br /> Minnesota Statutes, Cha ter 103I or W-series No. <br /> � (Leave blanh if n0�known) <br /> T-1 <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> �i'Ari0 1�� ?� 'j�� C'r "?^y,' r��^ �l—S— � �, <br /> 9 <br /> �� GPS Latitude degrees__ minutes__ seconds Depth Before Sealing � y3 ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds pQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer [�Multiaquifer ��'S . ' Z <br /> 17! ��-���r�� ��aaE+ '�r� (l�Cy�(� ,W}�'E�LUBORING �'Measured U Estimated Date Measured <br /> �y Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of weli ng � <br /> in section grid with"X:' location,showing pr per I_�Env.Bore Hole ❑Other _��ft. �,below [�above land surtace <br /> N lines,roads,and bw ings. CASINGTYPE(S) <br /> �' --'----'-----'— --'-- ��: <br /> �� � �]Steel [.]Plastic �_.]Tile []Other <br /> , � � � � <br /> ,� - <br /> ' '--- ' ` '-- ��.i� '��.� WELLHEAD COMPLETION ` <br /> W � ' � E T l � U A[Grade Inside: �Basement Offset <br /> . ,___ , r__ Outside: ❑Well House �` <br /> I � <br /> �: , , , i Miie _� �;Pitless Adapter/Unit ❑Buried i���Well Pit <br /> 5 <br /> �I � <br /> - --- - --- -- 1 ,., ) ❑Buried <br /> S ��Well Pit <br /> , T , ' ;� ❑Other <br /> �1 Mile� j ❑Other <br /> PR I �MP Y A 1 CASING(S) <br /> r _ ���COW�i�Ld��i Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Propeny owner's mailing address if different than well location add�ess indicated above ,i in.from � to �� S ft. [.]Yes u No U Yes ❑No ❑Unknown <br /> � G17 (?ak St <br /> - FarrRin�;ton, i�u� 5 JVG'+ in.from to ft. [_]Yes �_�No f]Yes ❑No �;Unknown <br /> in.from to ft. �j Yes �_�No n Yes ❑No ' :�Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> ? <br /> Well owner's mailing address if different than properry owner's address indicated above SCreen from_�� S to ��7 ft. Open Hole from____ ____to ft. <br /> OBSTRUCTIONS <br /> �]Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill I�-]No Obsiruction <br /> Type of Obstructions(Describe) ��t/F �'� j� t <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? �Yes L]No Describe <br /> FORMATION <br /> PUMP <br /> If not k�own,indicate estimated formation log from nearby well or boring. <br /> i /� (� <br /> �Jr �_�._ ` l �/ TYPe — <br /> ❑Removed [�Not Present ❑Other <br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE NOLE: <br /> �� q]No Annular Space Exists ��Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> ���. .____.__in.from _._________to tt. ❑Perforated U Removed [. <br /> in.from to ft. ❑Perfora[ed []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 �f�I� t"f" � � � from y� 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 Ofi REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesoia Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. <br /> �on Stc�lola t•Tell ��ilZin�; Ca., Inc. 1h�31 <br /> � <br /> Licensee Busine�N e License or Registration No. <br /> � j j � � > <br /> --''`,%,�,ir, r/ � �� �� � <br /> f <br /> died Representative Signahfre Certified Rep.No. Date <br /> , -�-..�� '� . <br /> � ����, " 3119�8 �` _�—� �-- � .__�,, _a 1�. <br /> t Name of Person Sealing Well or Boring <br /> - HE-01434-13 IC#140-0423 � sn2R <br />