|
Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed , s`i�f J Date Weil or Boring Constructed
<br /> _ � r 7 ..., -t i Prrx �� ;,irti: /� � + =�' �t�0
<br /> ,� �'.:m�...
<br /> GPS IOCATION-decimal degrees(to four decimal placesJ � � �
<br /> 1
<br /> Depth Before Sealing - k. Original Depth ft.
<br /> Latitude Longitude
<br /> AQUIFER(S) STATIC WATER LEVEL
<br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location v Singte Aquifer ❑Multiaquifer ,_ .
<br /> •�t.'
<br /> . ._,,_� _ _¢ -_ - WELLJBORING easured ❑Estimated Date Measured ��, � f�1i� ��/=r
<br /> _ ` � � ��Water-Supply Well �.
<br /> r]Monil Well
<br /> Show exac[location of well or boring � Sketch map of well or boring ` ���"'a
<br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other � ft. below ❑above land surface
<br /> N lines,roads,and buildings. CASINGTYPE(S)
<br /> ..L----'-----`-----'- °..� ���. ,
<br /> Steei ❑Plastic ❑Tile ❑Other
<br /> --;---"�----�-----�-- " . f._.. : ELLHEAD COMPLETION
<br /> , � � � , ( �� -.
<br /> w � � � � E `' �
<br /> 4 � ���.,
<br /> � � � � �1 _�.�7 � Outslde: ❑Well Nouse ❑A1 Grade Inside: �Basement Offset
<br /> --- --- ----------- 'h Mi�e � � ' ❑Pitless Adapter/Unit ❑Buried ❑Weli Pit
<br /> � . � � '
<br /> --.-----r----------=-- 1 ..___....___-�
<br /> ❑e����a
<br /> S ❑Well Pit
<br /> ❑Other
<br /> �--i Mae� ❑Othet
<br /> PROPERTY O A / MPANY NAME CASING(S)
<br /> '�""`�� ^�::_ �.'- : .� �``_'L`7?-C`:'S x�Y� DiamQter - � Depth • Set in oversize hole? Annular space indially grouted?
<br /> Property owoer's mailing addiess if dilterent than well location address indicated above L/ � � [� �
<br /> 7 in.trom (_...-' to_r._�__fl. ❑Yes �]No ❑Yes ❑No ❑Unknown
<br /> : . � •
<br /> G..,,�.,",' �'':.�.tl`3;��. �''p"� ❑Unknown
<br /> �r-,nrlt'_l�'__1�� ---
<br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No
<br /> : ,
<br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
<br /> ��� t
<br /> Well owner's mailing adtlress it diMerent than property owner's address indicated above �reen from � to T`��� $. Open HOIe from t0 ft.
<br /> OBSTRUCTIONS
<br /> ��Rods/Drop Pipe ❑Chedc Valve(s) ❑Debris ]FII ❑No Obstruction
<br /> '"!-- / �
<br /> Type of Obstructlons(Describe) /iL�/(,/F�� �^T,�i� `7''" i"�[�`�'�"���
<br /> GEOLOGICAL MATERIAL COLOR HFORMATONR FROM TO Obstructions removed? Yes ❑No Describe
<br /> If rwt known,indicate eslimated formation I irom nea PUMP „
<br /> og rby well or boring- -, �i h ,,,�
<br /> ,,.'",� i���� �, f } TYPe ��(' i U t� 1�-�
<br /> '� � � �Removed ❑Not Present ❑Other
<br /> 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 Perforation/Removal
<br /> in.from to ft. ❑Pedorated ❑Removed
<br /> in.from to tt. ❑Periorated ❑Removed
<br /> Type of Pertorator
<br /> VAFiIANCE
<br /> Was a variance granted from the MDH for this well? �Yes p No TN#
<br /> GROUTING MATERIAL(S) (One bag ot cement=94 Ibs.,one bag oi bentonite=50 ibs.)
<br /> 9 �ff--•:_`i. � .. ,�.� `Y r p
<br /> Groutin Material t`:^-;`i i��,:'Ifrom to " f 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 unsealed and unused well or boring on property? ❑Yes No How many?
<br /> LICENSED OR REGISTERED CONTHACTOR CERTIFICATION
<br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
<br /> is true to the best of my knawledge.
<br /> �.- '� ��_l,., :�s
<br /> Licensee Business Name License or Registration No.
<br /> � 7`-T`���/-•yf. .._..� i '.
<br /> (o,—L.:• _-J �4 �'.�
<br /> iCertified Representative Signature Certi(ed Rep.No. , Date
<br /> _ � . i
<br /> IMPORTANT-FILE WfTH PROPERTY H •� ;! "� F f� � '� `:{,,�,.,_., '"-, i.`z.,�, _
<br /> .._`��,--�.
<br /> PAPERS-WELL OYVNER COPY "�' "� �-►_�f`t ^ Name ol Person Sealing Well or Bonng
<br /> HE-01434-14 ID#53159 5/13R
<br />
|