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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �� WELL OR BORING LOCATION Sealing No. �, H County Name WELL.��AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Chapter 103/ °eaW,s e�ies No. � in Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed or«� Zi� 2� 03 r�° �r s� � v sF r o ,�r,r�� GPS Latitude____ degrees_____ minutes_____ seconds Depth Before Sealing CJ� ft. Original Depth ft. LOCATION: Longitude___ degrees______ minutes._,___ seconds �FER(S) STATIC WATER LEVEL � Numerical Street Address or Fire Number and City of Well or Boring Location ' ingle Aquifer ❑MuRiaquifer �n�.�/� /� �j I� F� St YL�� WE UBORING �INeasured ❑Estimated Date Measure /T/►�J' /�17 1 �Nater-Supply Well ❑Monit.Well � Show exact location of well or boring ketch map o we boring �i Env.Bore Hole ❑Other �v ft. elow above land surface . in section grid with"X." lo o rty � � N lin s,roads,and b 'Idi s. CASING TYPE(S) i � � � � � � � i --'-----�-- ---`-- ---•-- � � teel ❑Plastic ❑Tile ❑Other � � � � _ . --�--- --'--- ---`-- ---�-- ELLHEAD COMPLETION � � � W W ; � � ; ET � � � � �� Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset 'h Mile �qitless AdaptedUnit ❑Buried ❑Well Pit --,--- --r-- ---------=-- 1 ❑Buried S ❑Well Pit ❑Other �i Mile-� ,� []Other � PROPERTY OWNER'S NAMET/COMPANY NAME CASING(S) ��'i Final G � 1 Di�� f Depth�) / Set in over¢e ole? Annular space initially grouted? Property owner's mailing address if diflerent than well location address indicated above ,r-� �{j� _1jp.from �/ to ti.J 4►ft. ❑Yes � r]Yes ❑No ❑Unknown �i� $Ztif� DC JV�d�� I�4�d 55352 in.from to ft. ❑Yes� ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HO +++***�� Well owner's mailing address if different than property owner's address indicated above SCreen from�to "�� ft. Open HOIe ffom_ _to ft. �OB,SATRUCTIONS 'IY�Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fili ❑No Obstruction T �r^� Type of Obstructions(Describe) �� !�-- � ��„ +� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ��No Describe FORMATION If not own,indicate estimated formation log from nearby well or boring. PUMP � � � Type S �/ ` ` [�temoved �]Not Prese ._,Other ___,_ MET OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft ❑Perforated ❑Removed in.from to ft. J Perforated ❑Removed Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �/ /� /"� w � � Grouting Material/'-'�!'f `� ��' "'rfToPo �..� to ��R. yards� bags from to ft. yards bags from ro _ ft. yards bags �' OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? I_'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. , � I�Stadola �Tcli Dciilin�_ _ 1b91 Licensee Business Na e --�'"� /" License or Registration No. � �- /l � 9 -- - - - ------ ---- ie e resentative Signature..._ Certilied Rep.No. Date ------- - �� �-��,.�:��Y H 282669 ---- -- �-r,.- -,�.�,r,."-- Name of Person Sealing Well or Boring HE-01434-11 ICa 140-0423 � 2ioaa � .