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WELL OR BORING LOCATION MINNE$OTA DEPARTMENT�,OF HEALTH Minnesota Well and Boring („I �Q. Q <br /> WELL AND BORING SEALING RECORD Sealing No. V t,3 <br /> Counry Name Minnesota Unique Well No. ' <br /> ,�� in Minnesota Statutes,Cha ter 103/ or W-series No. /� � "`�� � <br /> � (Leava blank I(nol known) `J�� <br /> - Township Name Township No. Range No. Section No. Fraction(sm.–�Ig.) Date Sealed '�. Date Well or Bonng Constructed <br /> ��� 3 o r�ww r�s s� � v9 /9t� / <br /> , //�/ <br /> GPS Latitude_ degrees_____, minutes _ seconds Depth Before ealing ��� ft. Original Depth /f} ft. <br /> LOCATION: Longitude___ degrees__ __ minutes____ seconds pUIFER(S) � STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City oF Well or Boring Location . ingle Aqu er ❑Multiaquifer �,w���f /�,> <br /> W UBORIN �leasured ❑Estimated Date Measured ��i �r t A� <br /> � Water-Su I Well � <br /> p{}y ❑Monit.Well `�,/ <br /> Show exact location of well or boring Sketch map of well or boring i �C,{ <br /> in section grid with"X." location,showing property ❑Em.Bore F�ole ❑Other ft. �elow ❑above land surface <br /> N � 1 lines.���d bu�di j� CASING TYPE S) <br /> � f�?� v <br /> --�-----j--- --�— ---�- <br /> � I j j ; el ,J stic ❑Tile ❑Other <br /> te ' la <br /> � '"'"'-"''-'- ---`-- ---`-- � WELLHEAD COMPLETION �� <br /> W E � � <br /> � ' � __�_ ___;__ Outside: ❑ ell House ❑At Grade Inside: ❑Basement Offset <br /> ; --�-----�-- - T �11 <br /> '" �e s� �P tless Adapter/Unit ❑Buried ❑Well Pit <br /> --,-----r----.-�---:-- 1 � <br /> ❑V�ell Pit ❑Buried <br /> S ❑Other <br /> �-1 Mile—� ❑Other <br /> PRp��ER/T� WNpE R' ��}E�/CpOMPANY NAME CASING(S) � <br /> """�� " �"""" Dia e P! � Depth � Set in over1size`hole? Annular space initially grouted? <br /> Property owner's mailing address if diflerent than well location address indicated above �J I]�CI L]No n UnknoWn <br /> �in.fr m � to�ft. Yes ,�`.o � 1 Yes <br /> in.fr to ft. ❑Yes ❑No �]Yes �No ❑Unknown <br /> in.fr to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN OLE /'') <br /> Well owner's mailing address if different than property owner's address indicated above SCreen from � to �y�h Open Hole ffom to ft. <br /> OBSTRUCTION <br /> ❑Rods/Drop Pi ❑Check Valve(s) ❑Debris ❑Fill �o Obstruction <br /> Type of Obstruct ns(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions rem ved? �]Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not ku�own,indicate estimated formation log from nearby well or boring. <br /> U ( TYPe <br /> �]Removed Not Present ❑Other _ <br /> M_ETjiOD USED O SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> S�o Annular S ce Exists I_�Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.trom to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed �k <br /> Type of Perfor�ator <br /> ❑Other___ <br /> GROUTING MATE IAL(S) (One bag of cement=94 Ibs.,one bag of bento�ite=50 Ibs.) <br /> /jry .,.► �} /j�+//} / C <br /> Grouting Material ��� �r'r '���rom �✓ ' to�L�ft. yards� bags <br /> I <br /> � from to ft. yards bags <br /> i <br /> ._ from to ft. yards bags <br /> OTHER WELLS A D BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed an�l unused well or boring on property? ❑Yes �!o How many? __ _ <br /> LICENSED OR RE ISTERED 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 /> R.E.S. Well Dcilling Co,. Inc. a divisio� of <br /> Don Stalola WeI2 Drilling Co., Inc. 1691 <br /> � Licensee Busines$Na e `/ � � � License or Registration No. <br /> �'' •�''� �.�/ — t� , V � � / <br /> i' epreser�tative Signature – Certilied Rep.No. Date <br /> E % j. <br /> 1Q 1 � �.J�+.�����- � <br /> LOCAL COPY H �H i V O i — -- I -- --- ---- <br /> Name ol Person ealing Well or Boring <br /> HE-01434-11 IC#140-0423 2ioea <br /> � <br />