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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � j �°� � �� WELL OR BORING LOCATION WELL AND BORING SEALING RECORD MinnlegoNa Unique Well No. 1 � `)�- Co�nry Name� � Minnesota Statutes,Cha ter 1031 or W-series No. P (Leave blank it no�kn wn1 TT� ca; Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed � , �� m�aN �2 / � GPS Latitude___ degrees minutes seconds Depth Before Sealing /�� R. Original Depth ft. LOCATION: �ongitude degrees minutes seconds hA�QrUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location � �!'�1 Single Aquiter ❑Multiaquifer /�� 755 Fecn�al� R� �� tJ�fl� 553A1 1 W LUBORING �Measured L]Estimated Date Measured �� /'�" ,_]Water-Supply Well ❑MoniL Well � Show exact location ot well or boring Sketch map of well oc b rin - in section grid with"X" location,showing prope ty_ _J Env.Bore Hole ❑Other f�� _h. �below ❑above land surface N lines,roads,and tluildin�s. CASING TYPE(S) i �' __'___ __�__ ___`__ '_''__ ' � i { i Steel [;Plastic [;Tile [._�Other _ i -- - -- �y ! � WELLHEAD COMPLETION ` W ' ' ' E d II H G d I de t Off t :��. � � � � T • �' utsi e We ouse ❑At ra e nsi : i__!Basemen se � � � � --;--- --�--- --%--'--*-- � . � , . ; � � � � 'h nniie � � Pitless Adapter/Unit ❑Buried L J Well Pit . --,--- --,-- --.-----:- 1 ► [j Buried S ❑Well Pit ❑Other _______ - F--t Mile� . �_j OthBf PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Di�je� � Depth G � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above in.ffom �� I �] ��Unknown __ � to l�/ ft. �_,Yes �lo i__ Yes No in.trom ro ft. �]Yes (�Na ❑Yes [,No ❑Unknown _in.from to ft. I_]Yes L�No ❑Yes []No [j Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE , /� ,� ' Well owner's mailing address if diflerent than property owner's address indicated above Screen ffom �YJ� to �� ` ft. Open Hole from to ft. n t OBSTRUCTIONS Rods/Drop Pipe �, �Check Valve(s) ❑Debris ❑Fill ��No Obstruction Type of Obstructions(Describe)�/V/V�� T,� 9- /�� . GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �Yes ❑No Describe_ FORMA710N - PUMP If not known,indicate estimated formation log from nearby well or boring. t��Q ^ ..,i � /. � TYPe�.L',� {./[�/�---��- -�� ' � ` � '�� j�Removed ��Not Present ❑Other !� METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists ❑Annular Space Grouted with Tremie Plpe [j Casing Perforation/Removal in.from _ to ft. ❑Perforated �]Removed in.from_ to ft. ❑Perforated L�Removed a Type of Pertorator_____ ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �+ � r Grouting Material�F�,/ ��,�/�-�/ from__�__ to_f?,�__ ft. yards �'� bags i from to tt. yards bags _____ from_ to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused wetl 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. M1 � Stc�ala t,iell Drilli � Co I . Licensee Business Na e License or Registration No. ��:/�"! ._. �� / /�� .- r' epresentative Signature � Certified Rep.No. Date H •- �,��.-. _:-r'_:�: %:r --- LOCAL COPV 313 2 31 Name ol Person Sealing Well or Boring� HE-01434-13 IC#140-0423 5i72R