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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I ����Q O <br /> Counry Name <br /> WELL AND BORING SEALING RECORD Minneso a�Unique Well No. � <br /> �6I1l1e �.Q Minnesota Statutes,Chapter 1031 or W-series No. <br /> �Leave Dlank ii nol known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed <br /> oreno ��s a3 z6 3�-tro�: v — d <br /> . <br /> GPS Latitude degrees minutes seconds Depth Before Sealing �� ft. Original Depih 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 � ingle Aquifer ❑Multiaquifer /� <br /> Measured Estimated Date Measured��✓�'�' �/� <br /> WELUBORING ❑ <br /> • Q �VJater-Supply Well ❑Monit Well r <br /> Show exact location of well or boring Sketch map ot well or boring � �Env.Bore Hole Other <br /> in section grid with"X" location,showing property - ❑ �ft. �below ❑above land surface <br /> N ' � lines,roads,and bui�,gs. CASING TYPE(S) ; <br /> � Steel ❑Plastic [J Tile ❑Other <br /> � --'--- --'--- ---`-----'-- � ELLHEAD COMPIETION <br /> � • <br /> W : ; ; ; ET <br /> W <br /> .: � � _;____r__ . Outside: ❑Well House ❑At Grade Inside: asement Offset <br /> —;--- --�-- - � ��' <br /> 'h Mii� ❑Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> :` --�--- --�-- --�----�-- I '1 ❑Buried <br /> L ❑Well Pit <br /> S ❑Other <br /> �1 Mile� ' ❑OthBr <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter � Depth � Set in oversize hole? Annular space initially grouted? <br /> oper y owners mai ing address if diflerent than well location address indicated above �� <br /> _�in.from_�� to /I!/1 ft. ❑Yes �lo ❑Yes ❑No ❑Unknown <br /> 1820 �j�kevfev Terzace <br /> i�v�Q araa�0�: � 55356 in.from to ft. n Yes ❑No [�Yes ❑No ❑Unknown � <br /> in,from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> i <br /> Well owner's mailing address if diflerent than properiy owners address indicated above SCfeen ffom //v * to • �`� ft. Open Hole ffOm to ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> /�� ....� <br /> Type of Obstructions(Describe)���G.G ���J"� ¢ ti,,,/�'�l <br /> GEOLOGICAL MATERIAL COLOFi HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not ISnown,indicate estimated formation log from nearby well or boring. <br /> ..— ' � � l TYPe _. <br /> s <br /> r 1 Removed I�ot Present ❑Other <br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �vo Annular Space Exists U Annular Space Grouted with Tremie Pipe �]Casing Perforation/Removal <br /> /� <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 /> �' r ` � <br /> Grouting Material /t,�f�! ����L�1flom �+ to r �� ft. yards� bags <br /> from to ft. yards bags <br /> from to k. yards bags <br /> OTHER WEILS AND BORINGS <br /> qEMARKS,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 information contained in this report <br /> is true to the best of my knowledge. <br /> Don Stodola iiel Drlclifo9 Co. ,- Inc.. 1691 <br /> Licensee Business m License or Registration No. <br /> �- ,�i- a�; <br /> Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY �"� //� ^/ Q ���`������ <br /> - i.�i��J� Name ol Person Sealing Well or oring <br /> HE-07434-10 IC#140-0423 sio�a ` <br />