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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Seai ng No. ell and Boring �„I \� � �� ��� �
<br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
<br /> Minnesota Statutes,Chanter 103/ or W-series No.
<br /> � Y (Leave blank�il not known�
<br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
<br /> � T A �� � S
<br /> GPS LOCATION-decimal degrees(to four decimal places) �
<br /> Depth Before Sealing�__ft. Oriqinal Depih ft.
<br /> Latitude__ _____ ___ Longitude__ `
<br /> IFER(S) STATIC WATER LEVEL OF O
<br /> Numerical Street Addre-sNs or,,,F,i�re Number and City ot Well or Boring Location Single Aquifer IJ Multiaquifer �� .A�L/
<br /> 1(�5(� �',(��(.swtJlX:.t ��3�.'�e3 �� ('�rO�TA '� �VBORING �Measured [ IEstimated DateMeasured_ �3 1
<br /> ater-Supply Well !_-!Monit.Well Q ♦
<br /> Show exact location ot well or boring Sketch map of well or o�i �,Env.Bore Hole �C� �b (:1 above land surface
<br /> in section grid with"X:' location,showing prop rt� � ❑Other ,_.ft. elow
<br /> lines,roads,and buildi gsj
<br /> N ._,___..._ ��-, CASINGTYPE(S)
<br /> r.�.� �a
<br /> -_ -_- ---'-- --- _-_ ' � Steel '��]Plastic ! �Tile �I�Other —---_ — ___
<br /> '�� WELLHEAD COMPLETION
<br /> � W ' ' ' ' E T h t d II H t G d I d . � asement Offset
<br /> ; ; � � I �—� S`�� Ou si e: , ;,We ouse �J A ra e nsi e• �]B
<br /> -F----%- �� ,,,���///
<br /> ; ; ; , 'h M�ie �Pitless Adapter/Unit �Buried ❑Well Pit -_
<br /> Buried F
<br /> --�-- '-�-- -�- --�- � � LJ �,
<br /> S � w��- . I Well Pit ,..
<br /> t�
<br /> �Other
<br /> �—1 Mile� ��� .�R ', �:OfhBf _ �
<br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
<br /> � Diam er� f Depth � Set in oversize hole? Annular space initially grouted?
<br /> i
<br /> Property ownei's mailing address if differeni than well location add�ess indicated above �in.hom� to.��_ft. ❑Yes I�No `!Yes �__�No [__Unknown
<br /> Z��1� ���n�t0� .J1� in.from to ft. ��,...!�Yes I�_�No ']Yes [_�.No ❑Unknown
<br /> � r+�T 55391.
<br /> in.from to ft. ��Yes � 1 No ❑Yes [J No n Unknown
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � �+ �
<br /> Well owners matling address If dltierent than property owner�;address indica�ed above Screen from___I ��__to_ ���✓ ft. Open Hole from to __.__ft.
<br /> OBSTRUCTIONS
<br /> �Rods'Drop Pipe ��Check Valve(s) ❑Debris ��;Fill �No ObsVuction
<br /> Type of Obstructions(Describe)_����.___../ .�-I-'.�-__ 9" ��. ��
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes I_j No Describe_.
<br /> FORMATION
<br /> ' PUMP
<br /> If not known,indicate estimated formation log from nearby well or boring. U °
<br /> .� D /� TYPe�----�� ----- �.
<br /> !�emoved ��, f Not Present '�,_]Other _ _
<br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
<br /> � �No Annular Space Exists .-]Annular Space Grouted with Tremie Pipe �,__Casing PerforatioNRemoval
<br /> � in.trom __ . to______.___ _ft. i,�Perforated ;_'�Removed
<br /> i i�
<br />,,_� ,r- � _. _ In.from to__ ft [�Perforated � J Removed
<br /> Type of Perforator
<br /> VARIANCE
<br /> Was a variance granted from the MDH for ihis well? ,_,'�.Yes ��No TN# ._ _
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> /�� � /� f
<br /> GroutingMaterialN'�AJ(�/�rfrom__V r__ 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,DIFFICULTIES IN SEALING Other unsealedand unused well or boring on property? , Yes � o How many?___,__ _____
<br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION �
<br /> This well or boring was sealed in acwrdance with Minnesota Rules.Chapter 4725.The information contained in this report
<br /> is true to the best of my knowledge.
<br /> ?�cm �torlola �Iell Dci1li�Co�. In_c__.___1691 _ �
<br /> ------ - - --- - - _-_ _
<br /> Licensee Business N� e i License or Registration No.
<br /> i
<br /> . , '
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<br /> r� ..,.� , ,. ,- .�.
<br /> ,-. .. �� � �� -
<br /> ._.. ,�rf, , _ �. _
<br /> ' ,,°
<br /> - ------ -- — __---
<br /> ��R res ntative Signafur � Certified Rep.No. Date
<br /> 'H -- - ---- --- __ { .��
<br /> LOCAL COPY 3 3 3 0 7� Name o/Person Sealing Well or Bo�ing �
<br /> HE-01434-14 IC#140-0423 . S-i3R
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