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� � � ., . _ _ _., . _ _ . .. _ <br /> .. <br /> � ,s <br /> wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' <br /> Counry Name <br /> WELL AND BORING SEALING RECORD MennlesoNa Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> �Ledve blank i�nol know�) <br /> Township Name Township No. Range No. Section No. Fraciion(sm-->Ig) Date Sealed Date Well or Boring Constructed O <br /> (hono 11�3 23 36 1-�i5 . 2.U f}t� a� � ��1� <br /> GPS Latitude degrees minutes seconds / /�, / y�.*��,/�� � n-y- � <br /> Depth Before Sealing / �`�' ft. Original Depth /���t�7 tt. v�1 Y s <br /> LOCATION: V�: - <br /> Longitude degrees minutes seconds pQU1FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Weil or Boring Location ingle Aquifer ❑Multiaquifer �/ O <br /> WELUBORING QrMeasured ❑ Estimated <br /> � [�Water Supply Well ❑Monit.Well � <br /> Show exact locatio of well or boring Sketch map of well or � / ,�� <br /> in section grid with"X" location,showing pro rty�j ❑Env.Bore Hole ❑Other �—J ft �below ❑above land surface <br /> N ,\ lines,roads,and buildi S�z CASING TYPE(S) � <br /> 21( <br /> i i � i �W � v <br /> �_ _i__ __i__ __ <br /> '� TfE'Steel ❑Plastic ❑Tile ❑Other <br /> r� <br /> W -- - - -- - -- -- — E 0 �� WELLHEAD COMPLETION <br /> � � � � � � � Outside: ❑Well House Inside: ❑Basement Offset <br /> -�- -�-- -;— --�-- � <br /> Y�mi�e _,_ l �itless AdaptedUnit ❑Well Pit �` <br /> —�- -i-- -�-- --�— � � :ti . <br /> Y ❑Well Pit ❑Buried <br /> S <br /> �r mAe� -' <br /> ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANV NAME CASING(S) <br /> T � 952-47fr2581 Diameter/� Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if ditterent than well location address indicated above � ���/ <br /> � in.ffom�__ to��,ft. ❑Yes �yNo ❑Yes ❑No ❑Unknown <br /> r� <br /> in.frOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> In.f�Ofn t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> ♦ � <br /> Well owner's mailing address if different ihan property owner's address indicated above Screen from � t0��ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS � <br /> �iods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstjruction <br /> Type of Obstructions(Describe)�L(/1�/� �rI'� �'" / V��� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Y2S ❑ NO D2Sc�ib2 <br /> FORMATION <br /> If no�known,indica�e estimated formation log irom nearby well or boring PUMP <br /> ` J�i TYpe ��.i��. �/)�'� ("? <br /> �� � r�yrvr <br /> [�Removed ❑ 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 ❑ 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 /> n; < yy�,t-�" a �'� � � <br /> Grouting Material ���/Y ��i` om t ft. yards bags <br /> from to ft. yards bags <br /> from to ft. 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 o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The informalion contained in this report is <br /> true to the best of my knowledge. <br /> Don Stvdiiia �ell Drilling Co, Ir�c. 27I72 <br /> Contractor Business me _ � License or Registration No. <br /> , ,� 1 - ��3 <br /> o d es'ntative gnature.- Date <br /> �..-r�-- •_..�.�"� ,A..J�V�-:CUI�C�-' . <br /> LOCAL COPY H 213 7 71 Name ol Person Sealing Well or�� <br />