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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �''i 1 �ounty Nam� WELL AND BORING SEALING RECORD M nneso a�Unique Well No. � r �'` ��erme�ir. Minnesota Statutes,Chapter 1031 or W-series No. (Leava Wank ii no�known) T i��{� Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Construct�i�� fl 7 7 O�� �r�rac� 117 2'� t�L� cc.a ewr �a � f �� u i � GPS LOCATION—decimal degrees(to four decimal places) �r ' C�-�y p��RONO Depth Betore Sealing /�� ft. Original Depth Latitude Longitude UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �n�/ *+ r WELUBORING Measured ❑Estimated Date MeasuredS�ml �N7I 3�?75 �arvi��r T.�n�, �c�nn �5356 �Water-Supply Well ❑Monit.Well � � Show exact location of well or boring Sketch map of well or boring in section grid with"X:' location,showing property ❑Env.Bore Hole ❑Other �J ft. �below ❑above land surface lines,roads,and buildings. N CASING TVPE(S) I � I ; _..__.___....._. --'---—y---_`_---''- .;�1' k � �teel [�Plastic ❑Tile ❑Other --'-----'------`-----'— i ,. i �" WELLHEAD COMPLETION W : ; : ; ET , e __�_____�_____�_____r__ �`�„_ Outside: �Well House ❑At Grade Inside: ❑Basement Offset , , , ; �Miie eess A p r/Unit ❑Buried ❑Well Pit , , , , �Pit da te --�--- --T—---%-----�-- , � , , ❑Buried � � S ' ' �� ❑W IIP't �•�,�t'��`"" ❑Other �1 Mile—� _. ,.�.�-�`�'��"� ❑Other__ PEIOPERTY WNE ' NAME/COMPANY NAME CASING(S) �"c�� t��ra�'ln Diam t�' { Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diNerent ihan well location address indicated above ��n.ffom Q to/�Z R. ❑YBS �No ❑Yes NO ❑ ❑Unknown in.from ro ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from ro ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE i / / r Well owner's mailing address if different than p�operty owner's address indicated above Screen from1�tof�Lt�ft. Open Hole from to ft. OBSTRUCTIONS �,/ ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �y No Obstruction � � Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. "�y� ` Type_ �, 1 t-- r� t—��[�Removed �lot PreseM ❑Other �� � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to R. ❑Perforated ❑Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? ❑Yes ` o TN# GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite-50 Ibs.) �}� � l � Grouting Material/�/l��i��1`�/from � to� � ft. yards � bags from to it. yards bags from_ to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes No 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 true to the best of my knowledge. t)on Sto�ala t�Tell I�riZlic�� Co., Inc. 1591 Licensee Business N e `, License or Registration No. ,, ,�� .-__. _ J � �d ""✓" ,. - �„�,j /..i � C� entaf e ignature,. Certified Rep.No. Date pz "'�r". .� ".� �' -....!:�.; ,q ti, "`,•`i: 1��.vR-�'.`. ��.=4'' `i' LOCAL COPY H =i ai�� Name ol Person Sealing Well or 8 ring HE-01434-14 ID#53159 . SnsR