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wELL OR BORING LOCAT1oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring F„I !"�����Q <br /> County Name <br /> WELL AND BORING SEALING RECORD Minne oNa Unique Well No. L �� <br /> � Minnesota Statutes,Chapter f03/ or W-series No. <br /> (Leeve denk H nol bwwn) <br /> Township Name Township No. Range No. Section No. Fraction(sm-�Ig) Date Sealed Date Well or Boring Constructed <br /> {?cono 118 2� 36 4#-()007,. <br /> GPS �b�� degrees minu[es seconds � � <br /> LOCATION: Depth Before Sealing ���ft. Original Depth ��_ft. <br /> Longitude degrees minutes seconds pQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Locadon Single Aquifer ❑Multiaquiter <br /> 1 WELUBORING Measured ❑Estimated <br /> � 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 ❑Env.Bore Hole ❑Other �ft. bebw ❑above land suAace <br /> N � lines,r ,and buildings. CASING TYPE(S) <br /> - - - - - -- - — `..��, + <br /> Sleel ❑Plastic ❑Tile ❑Other <br /> W -- - -i-- - -- --i— E WELLHEAD COMPLETION <br /> � � � Outside: ❑Well House Inside: ❑Basement Offset <br /> -;r- ---- -;-- -i-- <br /> , '� ' � �� �Pitless AdapterlUnit ❑Well Pit ' <br /> --;- -�-- -i-- --�-� r� .; - __ <br /> 1 �.r✓ ❑Well Pit ❑Buned . <br /> S <br /> �—�,�.—�. �;�:,"��-� <br /> ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAM�E�/ e� CASING(S) <br /> �$'(� 76J�'F7�7�G Diameter Depth , Set in oversize hole? Annular space initialty grouted? <br /> Property owner's mailing address rf difFerent than well location address indicated above �` <br /> � in.ffom�_ to��ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> 27Q5 Cty Rd 19 <br /> ��s � ��3g9 in.ffOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> Well owner's mailing address if different than property owners address indicated above Screen from t0 ft. Open Hole from �/ / t0���ft. <br /> c�i r <br /> OBSTRUCTiONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describ@�„��!t,ey�,� /'f��(�� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ NO D2SCflb2 <br /> FORMATION <br /> I(not known,indicate estimated tortnation log hom nearby well or bonng PUMP � <br /> d[ift Q 21 TyPe <br /> Removed� ❑ Not Pres nt ❑Other <br /> �$t(� �� 1 � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PeAoration/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br />�' <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 /> / <br /> Grouting Material�� ,��i ,T �""���—�to��ft. yards �� bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES 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 Rufes,Chapter 4725.The informabon contained in this report is <br /> true to the best of my knowledge. <br /> Ilon Stcx3ala 6�12 Dcilling Co, Inc. 27172 <br /> Contractor Business Name _ License or Registration No. <br /> � ..... � :.% . � �~ !�lY"l)Y <br /> .,- �. . _s- �� �,_ <br /> . o Re�resentahve SignaWre� Date <br /> .T�.E1 �IiCOTl�[1 <br /> LOCAL COPY H 2 2 51_18 � <br /> Name of Person Sealing Well or Bonng <br />