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�y — MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„� <br /> WELL OR BORING LOCATION Sealing No. <br /> �o��H Nema WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> tze�ssKyic� ti,;.,.,esora Statutas,Chapter ios� o�W-�senes�No. <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constnicted <br /> .,, �,_ ��f.r� � <br /> GPS Latitude degrees minutes seconds -� � <br /> LOCATION: Depth Before Sealing ��`'� ft. Original Depth ft. <br /> Longilude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fre Number and City of Well or Boring Location ingle Aquiter ❑Multlaquifer � <br /> WELUBORING �easured ❑Estimated <br /> ��' '+_�lNVater Supply Well ❑Monit.Well � � <br /> Show exact location of well or boring Sketch map of well or bo'ng �r � <br /> in section gnd with"X" location,showing prope '�. ❑Env.Bore Hole ❑Other �� ft. �below ❑above land surface <br /> N lines,roads,and buildin � CASING TYPE(S) <br /> - - - - - -- - -- ._�.._...i ;k. <br /> +. � ` �teel ❑Plastic ❑Tile ❑Other <br /> _tt <br /> W --�- - - - -- --i-- E .. WELLHEAD COMPLETION <br /> � -- Outside: ❑Well House Inside: ❑Basement Offset <br /> _Y_ ____ 'j__ _�_' <br /> � �tmirs � ' �YPitless AdaptedUnit ❑Well Pit <br /> --�- -�-- -�— -i-- I ,�� 7t <br /> 1 - ` ❑Well Pit ❑Buried <br /> S <br /> �—�'"�----� , �.\' \ ' �` ❑Buried <br /> ia <br /> PROPEyR*TY.tOWNcER'S NAME/COMPANY NAME CASING(S) <br /> �1 ti t? t4 � Diameter, � Depth � Set in oversize hole? Annular space initialty grouted? <br /> Property owner's mailing address H diflerent than well location address indicated above � <br /> � in.ffOm_t� t0��ft. ❑Yes 19iIVo ❑Yes ❑No ❑Unknown <br /> 11401 Cty Rd. 3 '` <br /> �Slj.s�' � ��.�)�g in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> r��.� J�tJ <br /> in.f�om to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> r � <br /> Well ownei's mailing address N different than property owner's address indicated above Screen from�t0 z.,� ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> '�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) �,R/�t��, '�_�j� ¢ �� � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 2S ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated tortnation log from nearby well or boring PUMP <br /> �-�� � ,r;� � TYPe �C7`.I2'�, �tl�l`1(J <br /> Removed ❑ Not Present ❑Other <br /> �' <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �[fJo Annular Space Exists ❑ Annular space grouted with iremie pipe ❑ Casing PeAoradon/Ftemoval <br /> !� <br /> in.from to R. 0 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 bentonRe=SO lbs.) <br /> ,,�y' /� � -ry�.,,� ' <br /> Grouting Material ,l�/�C,!" '-U� from � to�:L„�t. yards �� bags <br /> fram to ft. yards bags <br /> from to k. 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 o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The infortnation contained in[his report is <br /> true to the best of my knowledge. <br /> I�n Stalola �e12 Dril2ick; Co,. Inc. 2727.?. <br /> Contracfor Business am License or Registratlon No. <br /> :_—� r _ �' � <br /> . - : _ .. . _,: <br /> A riz e resentafive Signature• Date <br />� � R, . �✓ <br /> ,��.... . ...--�,-�.,.f��y' <br /> LOCALCOPY H 5� <br /> Name of Person Sealing Well or Boring <br />