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s.. <br /> S MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I <br /> � WELL OR BORING LOCATION � WELL AND BORING SEALING RECORD Minnleso a�Unique Well No. <br /> � County Name <br /> Minnesota Statutes, Chapter 103/ or W-series No. <br /> (Leave blank il not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Conshucted <br /> � S�W C� -� In �7 <br /> _ � <br /> GPS Latitude__ __ degrees__ .__ minutes_. _ seconds Depih Before Sealing � �J k. Original Depth ft. <br /> LOCATION: Longitude_, degrees_ minutes _ seconds <br /> – �IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �/�M /�/ <br /> 2pV1 P(n[ Jt �� 55356 WELUBORING �vieasured ❑Estimated Date Measured �/���"� �i'/ <br /> Water-Supply Well ❑Monit.Well 1 <br /> Show exact location of well or boring Sketch map of well or boring �- <br /> in section grid with"X." location,showing property ��. �Env.Bore Hole '�]Other �ft. �below ❑above land surface <br /> ,� lines,roads,and buildi s. �� <br /> ; N � ASING TYPE(S) " <br /> --'--- --i----"----'- �: <br /> Steel ❑Plastic ❑Tle ❑Other <br /> � --i--- --�-- ---F-----7-- WELLHEAD COMPLETION � <br /> w ; ; ; ; ET <br /> � � � � � V,� Outside: ❑Well House U At Grade Inside: ❑Basement Offset <br /> --�--- –;--- --�-----*-- � <br /> , , , , Mile �Pitless Adapter/Unit � uned , ell Prt <br /> �h � g ' ]W <br /> ------------ ---------=- 1 <br /> , - ��Buried <br /> S ❑Weil Pit <br /> � ❑Other <br /> �-1 Mile—� - ❑Other <br /> PROPERTY OWNER'S NAME/COMPAN ME CASING(S) <br /> Diame e�� /) � Depth / � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above � in.frOm `� to � r ft. ❑Yes �No ❑Ye5 ❑No ❑Unknown <br /> _in.from to ft. ❑Yes ❑No (]Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes [�No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> r � <br /> Well owner's mailing address if diflerent than property owner's address indicated above SCreen f�om r�' to � � Jtt. Open Hole ffom to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe [�Check Valve(s) �.,_j Debris �Fill �No Obstruction _ <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? ❑Yes ��No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> � � Type _ <br /> �;�Removed [�lot Present ❑Other - <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �o Annular Space Exists �]Annular Space Grouted with Tremie Pipe �Casing Perforation/Removal <br /> in.from to ft. [j Perforated ❑Removed - <br /> in.from to______ ft. ❑Perforated ❑Removed <br /> � <br /> Type ot Perforator__ _____ _ <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> � <br /> �.+r I � <br /> Grouting Material/U'��� C�J�'L U�from d to� ft. yards�� bags <br /> from to __ ft. yards bags <br /> from ro _ ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICUITIES 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 /> � RE.S �Iell Arilling Co., Icrc. a division of <br /> ;' ----- -A��todo].a_ �2r�lling-Co��_Icic�_ 1F�1 __. _ _ <br /> Licensee Business Name License or Registration No. <br /> _ _ �-,�3 a � <br /> en ative � u Certified Rep.No. Date <br /> � -- ----—� --�- — � '� ' <br /> H 275530 �-���-- ` <br /> LUG��.L COPY Name of Person Sealing Well or Boring � � <br /> --- -- _ _ <br /> HE-01434-11 ICn 140-0423 � 2/oea <br />