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: WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„� ��(�� County Name WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. J Minnesota Statutes,Chapter f03/ or W-series No. (Leeva blank it nol known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed 118 23 31 5W 1� � � �T ' / , GPS Latitude . degrees___ minutes___ seconds Depth Before Sealing /• � ft. Original Depth � ft. LOCATION: Longitude_ degrees minutes seconds -- �IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer /�,7 4355 Chi LII� ��a� 55359 WELL/BORING Measured ❑Estimated Date Measured ��'�� ',i/"�N �Water-Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or boring �Env.Bore Hole Other ft. below in section grid with"X:' location,showing properly ❑ � � ❑above land surface �} � lines,roads,and buildi s N � �� ; :�'�q. CASING TYPE(S) j �teel ❑Plastic ❑Tile ❑Other - �� --�--- --''-- -"`"'""�"" ELLHEAD COMPLETION 7` �' W � � � � E � � f W " :; � � _;____;__ T Outside: ❑Well House ❑At Grade Inside: [�Basement Offset �.. --;--- --�— - � �!� , , , , Mile itlessAdapter/Umt �Buried ❑Well Pit 'h , , � ❑p. ! —�•-- --T-- --�----�- �.� ❑Buried S � \\ � �.i Well Pit �i Miie—� `�0 ❑Other ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diameter r Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diNerent ihan well location address indicated above ' , 7 �� in.from� to�R ❑Yes �No ❑Yes ❑No ❑Unknown v 370 Wa,�erSt I�ccelsior, M[� 55331 �n.from to R ❑Yes ❑No [�Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE , � �� Well owner's mailing address if different than properry owner's address indicated above SCreen from ��to ,� ` ft. Open Hole from to R. OBSTRUCTIONS . � ❑Rods/Drop Pipe ❑Check Valve(s) �ebris �Fill ❑No Obstruction Type of Obstruclions(Describe)__�I�'�/�� /X�T � /,�t� HARDNESS OR � GEOLOGICAL MATERIAL COLOR FORMATION FROM TO Obstructions removed? es �_]No Describe _ . PUMP If not known,indicate estimated formation log from nearby well or boring. d�lt V �� Type_ j :Removed �Vot Present ❑Other___ . � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: j�Jo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to__ ft. ❑Perforated ❑Removed in.from to ft. �'Perforated ❑Removed Type of Perforator ___ __ ._ __ ____, F ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) r � Grouting Material /�/�C-�j T [�+��'�_l�m__��__ to�_I� ft. yards_�___ bags _ ____ from to ft. yards bags from to ft. yards_ bags OTHER WELLS AND BORINGS REMARKS,SOUHCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? '�.I Yes � o How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION �: This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is hue to the best of my knowledge. ? non scoaola well nriTling cos. Ir�, 1691 - ---- - --_ - - ------- -- Licensee Business am License or Registration No. ' a �-� 4-8�-04 rtifi epresentative�Signature�� Certilied Re .No. �� Date� P --- ---- LpCAL COPY H 2 7 fi 9 2 3 II ---- 1� ��----- --- Name ol Person Sealing Well or Boring � J4, HE-01434-11 IC#140-0423 —�---�--- ..._ . - ..I��.. . ......---- --- �--� ...� � �� 2/08R