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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„I ��`*"„�]'�� <br /> - WELL AND BORING SEALING RECORD M nnle90 aoUnique Well No. �� � <br /> County Name <br /> x�--�p' Minnesota Statutes, Cha/�ter 103/ or W-series No. <br /> +�i.iN1Gp�� r (Leave Dlank�i�not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> � ii� 23 cw sw n��' s� ia � iv <br /> , <br /> GPS Latitude__ _ degrees_____ minutes__ seconds Depth Before Sealing �� ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes____ seconds UIPER(S) � STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer G ,-�t�l <br /> W LL/BORING 'Measured ❑Estimated Date Measured_.J I�'/�� �� <br /> Water-Supply Well ❑Monit.Well f <br /> Show exact location of well or boring Sketch map of well o oring S�+ <br /> in section grid with"X" location,showing pro rty ����Env.Bore Hole ❑Other ft. �below ❑above land surface <br /> lines,roads,and buil gs. <br /> N CASING TYPE(S) <br /> � --'--- --i-- ---'-----'-- <br /> �� Steel ❑Plastic ❑Tile ❑Other <br /> :'�� ; I I I �� <br /> ----- -- --- -------- -- WELLHEAD COMPLETION <br /> W : ; � ; ET <br /> '� � � _�____r__ � � Outside: ❑Well House U At Grade Inside: ❑Basement Offset " <br /> 'h Miie `t ❑Pitless Adapter/Unit �Buried ❑Well Pit <br /> - 1 ' <br /> �j `]Buried <br /> S ❑Well Pit <br /> ❑Other <br /> F--1 Mile—� �-- 1 ` ❑Other <br /> \..�� <br />. . PROPERTY OWNER'S NAME/COMPANY N i CASING(S) - <br /> Diameter � Depth � Set in oversize hole? Annular space initially grouted? - <br /> Property owner s matling a ress rf di erent t an well lowtion address indicated above // � <br /> �in.from_�__ to�ft. ❑Yes [�Vo ❑Yes ❑No ❑Unknown <br /> 15050 23cd AV� N in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> P2ymaiih, � 55447 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � ' <br /> Well owner's mailing address if different than property owner's address indicated above SCreen from_C to�__ft. Open Hole ffom to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �]No Obstruction <br /> I <br /> Type of Obstructions(Describe) ����(J/J� / /�1��/Y� ���J <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe <br /> FORMATION <br /> If not k�own,indicate estimated formation log from nearby well or boring. PUMP . � . <br /> Type — <br /> ❑Removed —' ot 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. ❑Perforated ❑Removed } � <br /> in.trom ro ft. ❑Perforated ❑Removed <br /> Type of Perforator � <br /> ❑Other _ <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> � -�'' i � <br /> Grouting Material�,��!__�f'��C✓ffom�_ to� 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 CONTRACTOR 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 knowledge. <br /> Uon Stodols t�e21 nri.11in� Co,. Inc. I691 <br /> � Licensee Business Name License or Registration No. <br /> � <br /> ' .. / � r%•�J <br /> C p. s� �� � � ture � � " CertiliedRep.No. Date <br /> " 285708 �j� <br /> LOCAL COPY Name o/Person Sealing Well or Boring t <br /> HE-01434-11 IC#140-0423 � 2/OBR <br />