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. _ <br /> . <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH M nnesota�J-��and 3onnr� �,.� �O���� <br /> Counry Name <br /> WELL AND BORING SEALING RECORD M;��e9ot°un�q�e we��rvo. ----- <br /> Minnesota Statutes,Cha ter 1031 or W-series No. <br /> � ILe::�ve blank il n01 hnOwn) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> � N �2 <br /> GPS Latitude degrees minutes___ seconds Depth Before Sealing �Sd � ft. Original Depth ft. <br /> LOCATION: Longitude_ degrees_ . minutes seconds A UIFER(S) STATIC WATER LEVEI <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer t /��`�/ <br /> �j, WE�L�BORING �Measured �Estimated Date Measured �7��� !J►'Jr <br /> TT ,�Water-Supply Well i�Monit.Well �/�♦ <br /> Show exact location of well or boring .���S ketc map of well or boring Env.Bore Ho�e Other ✓`� ft. below <br /> in section grid with"X." 55-n�"Rocation,showing property. ❑ ___ � ❑above land surface <br /> lines.ro�ds apd bwldin s. - <br /> � N -,.9_� 1 G-[ a (_� _.:�.h..-- CASING TYPE(S) <br /> � ' '-- -'.� i _:__ ,. <br /> � <br /> � � � _ <br /> �• � � � � ' I�Steel I,]Plastic :_'�;Tile ����Other ` <br /> � , , � � . <br /> , j <br /> �- ------ --.._------ ' <br /> �� --�--- --�--_==-f- >-' � WELLHEAD COMPLETION � <br /> - — <br /> : W � � � � E �� .. _ <br /> � , <br /> � __�___ __,__ ' _�__ T t Outside: �. .Well House L�At Grade Inside: ❑Basement Offset ` <br /> ' � ; � ��AA° � �Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> '-- 5 -% ---�— [ <br /> � [�Well Pit ❑Buried <br /> �-1 Mile—� ! � -�Other ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diam �� � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owne mail�ng ad ress d diflerent than well location address indicated above �j/ - <br /> �in.from Q to1�ft. ❑Yes [�lo f_I Yes ❑No ��Unknown <br /> in.(rom to ft ❑Yes ]No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes �,I No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAMElCOMPANY NAME SCiiEEN/OPEN HOLE <br /> • � <br /> Well owner's mailing address if diflerent[han property owner's address indicated above SCfeen from_���to���_ft. OpBn Hole from to ft. <br /> OBSTRUCTIONS <br /> .�ods�Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)_ _�1�� /G� P�T�SS _ __._ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? (�Yes [_�No Describe <br /> FOHMATION <br /> If not kno.wn,indicate estimated formation log from nearby well or boring. PUMP <br /> �/--'-� /y r."r TYPe . <br /> "� � ��' � !Remaved �Not Present <br /> ❑Other <br /> :��� METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ��lo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> � Type of Per(orator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite-50 Ibs.) <br /> � i � <br /> Grouting Material /�k/qT�,�J��.J/ irom� to_fSQ 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 ( o How many? � <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Fules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. <br /> Don Siodola Well Driliing Co,. Inc. 1b91 <br /> Licensee Business Name ��� License or Registration No. <br /> + <br /> � , � � <br /> /� . <br /> C �ed presenta�ve i ature Certilied ep.No. Date <br /> , <br /> LOCAL:COPY H 3 V 5�6 6 --- ` '�w r� `.Ni �-}' �.,.t'v r...r <br /> � � Name of Person Sealing Well or Borin��: <br /> HE-01434-12 IC#140-0423 gi09a <br />