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� WELL C>F BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' �� /� �� � County Name WELL AND BORING SEALING RECORD Minnle9oNa Unique Well No. 't {�{ Minnesota Statutes,Cha ter 1031 or W-series No. � �i3i P [Leave blank i�no�knownl Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Conshucted � o,� ii� Zs o2 3�-cx�o2�� q�� . _ .._,t i GPS Latitude degrees minutes seconds Depth Before Sealing_ o�� ft. Original Depth ft. LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and Ciry of Well or Boring Location Single Aquifer (_J Multiaquifer ,�f� /� /� 1520 Fox St, V� ,75.77� �W/ELUBORING �easured ❑Estimated Date Measured r'',��l�iF iJ17 �y-Water-Supply Well ❑Monit.Well �^ � Show exact location of well or boring Sketch`rCap of wel�'�r boring �Env.Bore Hole ❑Other ��``�6�(;J ft. �below �- 1 above land surface in section grid with"X" y�qc�aSjjprl,s 'n I �rty —� ;�,,_,,.,.�. �� N � " � 9S� CASING TYPE(S) , � . _''___ __�'_ ___`__'__'__ ' . � � �I ❑Plastic ❑Tile ❑Other --'--- --+-- ---`-- ---'-- � � WELLHEAD COMPLETION W E �� - �� Outside: '�"�Well House 3rade Inside: �;Basement Offset 'h Miie � � _ �itless Adapter/Unit ��uried L]Well Pit -- --- - I j .^ ]Buried _L � � ❑Well Pit S ]otner �--1 Mile--{ �I L_Othef PROPEATY OW/�1 ER'S NAME/CO^M�PA,,�N�Y{j E � CASING(S) ��/J�e 1�.�1J.J.n / /� r De�'� � Set in oversize hole? Annular space initially grouted? -� Properry owner's mailing address if diflerent than well location address indicated above �1 `� rOm `� t0�� _ J Yes �No ❑Yes ❑No ❑Unknown .� 881� �8 !1�'1QVe .,� in.from to __ ft. ❑Yes [�No ❑Yes ❑No ❑Unknown � in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � Well owner's mailing atld�ess if diNerent than property owner's address indicated above SCreen frorr��_to��f ft. Open Hole from to R. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) I]Debris '_��Fili � �bstruction Type of Obstructions(Describe) __ . , . GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. - _.��` / TyPe � `� •�� ❑Removed �1'!ot Present ❑Other _._ i l � METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: [�Jo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal - in.from to ft. ❑Perforated � �Removed in.from to ft. ❑Perforeted []Removed � Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Materi�/*/ C.r/��F��from � r �� . yard�_�� bags from to ft. yards _ bags ___ from to ___ ft. yards bags OTHER WELLS AND BORINGS �, REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well 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. D� Stodoia iiSll Dcillin� +Co,. Inc. l�91 Licensee Business Name License or Registration No. / �� - �/ .�7 d epresentative Signatu�e Certified Rep.No. Date _c�;;,�^o�v H ��,-.� �,�.... ..��,...� 2 6 4 3�6 Name ol Person Sealing Well or Boring HE-01434-10 IC#140-0423 5/o�a .:.;