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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �Q���O <br /> WELL OR BORING LOCATION Sealing No. H J <br /> County NamA► WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br />� ' Minnesota Statutes,Cha ter f03I or W-series No. <br /> P (Leave blank il no�known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> �j_� � - �� tik�ownl <br /> GPS Latitude degrees minutes seconds Depth Before Sealing � O�� ft. Original Depth t p�,��f' ft. <br /> LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer [ J Multiaquifer �f��� _ f i <br /> o L WELL/BORING �Measured ❑Estimated Date Measured 1 � <br /> ZSC� P � 4 I'�,Water-Supply Well �Monit Well <br /> Show exact location of well or boring Sketch map of well or boring . <br /> in section grid with"X." location,showing property J Env.Bore Hole ❑Other �Q fl. �below ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> --'-- --j--- ---`-- ---'-- ' ,. <br /> Steel ❑Plastic ❑Tile [_.I Other <br /> � � , � > <br /> . � � � � •- � <br /> ' --'--- --�------�-- ---�-- WELLHEAD COMPLETION <br /> : W � � � � E <br /> ' ______ ______ ___;_ ___�__ T ` Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset i <br /> 'h M�ie �Pitless AdaptedUnit ❑Buried ❑Well Pit <br /> � --�-----T-- —�-- --�-- I e i <br /> , , , ' L �i ❑W II P't ❑Buried <br /> � � S , � � <br /> F--1 Mile--� � ❑Other ❑�ther <br /> � <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Properry owner's mailing address if different ihan well location address indicated above !J a <br /> 7 in.from .J to �Ot � ft. ❑Yes �,No ❑Yes �No []Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No LJ Unknown <br /> in.from to ft. ❑Yes ❑Na ❑Yes ❑No �l Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mai�ing address if different than property owner's address indicated above Screen from�to `�� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑Check Valve(s) ❑Debris Fill �]No Obstruction <br /> � <br /> Type of Obstructions(Describe)_ ����� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OH FROM TO Obstructions removed? �Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. t� <br /> � \-�r,� �TYPe S�.�3 <br /> �Removed ❑Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �j,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 i__�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{V�p7 L��r�nT,,om_Q_ to �a 5 ft. yards 'Q 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 �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 /> Dc�ci Stcxit�la Well Drillir�, co., Ir�c. 1b92 <br /> _ � <br /> Licensee Business Na License or Registration No. <br /> - �- <br /> � /�/ t � <br /> erG' d presentative Sign Certilied Rep.No. Date <br /> LOCAL COPY H 2 9 3 5 5 0 � ' <br /> Name of Person Sealing Well or Boring <br /> HE-01434-12 IC#140-0423 9/09R <br />