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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 4 4 3 0 4 Counry Name WELL AND BORING SEALING RECORD Minneso a�Unique Well No. Minnesota Statutes,Cha ter 1037 or W-series No. P (Leave blank il nol known) ti Township r�e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed +^rc��cs 117 ?� r?r -�;� 9g �.: 2. GPS LOCATION-decimal degrees(to four decimal places) (� / Depth Before Sealing V� ft. Original Depth ft. Latitude Longitude IFER(S) STATIC WATER LEVEL Nu or Boring Location Single Aquifer ❑Multiaquifer �,/ yYEyLiBORING �Measured ❑Estimated Date Measured,��l �'��" f'-�-��^ - - " '�vater-Supply Well ❑Monit.Well / Show exact location of v/ell or borin Sketch ap of well or boring in section grid with"X." locatio ,showing property ❑Ern.Bore Hole ��Other �ft. I,�below ❑above land surface line oads,and buildings. CASINGTYPE(S) . ..1 i . _ -.. � � � � , � ,', �. --'----i- --`-- ---'-- ' �,/ „J ; IYSteel ❑Plastic ❑Tile ❑Other 7\ --'--- --i--- ---h-- ---t-- f WELLHEAD COMPLETION � � , � .�._�_. W ; : ; : ET �,/ � � � � Outside: ❑Well House ❑At Grade Inside: IR Basement Oftset --;--- --�----%-- --%-- �'- ; ; ; , 'h nniie � ❑Pitless AdapteUUni[ ❑ uned Well Pit B ' � --�--- --�-----�----�-- s J ❑Buried � 1 �� ❑Well Pit S ❑Other �i M;ie� ❑Other PROPERTY OWNEA'S NAME/COMPANY NAME CASING(S) ��lr�.i' ��:�7V�:�2.bl ' Diameter / Depth / Set in oversize hole? Annular space initially grouted? Property owner's mailing address if ditte�ent ihan well location address indicated above �� �in.from � to ft. ❑Yes �Jo ❑Yes ❑No ❑Unknown ��v ;��$t N111. n� in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown (,TFIteCtOWlI� 1''�? )rj'�t,t� in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � f Well owner's mailing address if diflerent than property owner's address indicated above Sc�een from__�_to�ft. Open Hole ffom to ft. OBSTRUCTIONS �Rods/Drop Pipe �]Check Valve(s) ❑Debris ❑Fill ❑No Obstruction Type of Obstructions(Describe)�I�w�JC �� " V�j GEOLOGICAL MATERIAL COLOR HARONESS OR FROM TO Obstructions removed? s � i No Describe FORMATION PUMP I(not known,indicate estimated formation log from nearby well or boring. Type '� ❑Removed �Not Present ❑Other METHOD USED TO 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. ❑Perforated ❑Removed Type of Perforator_,__ VARIANCE � Was a variance granted from the MDH for this well? �_;Yes � No TN# GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material N��.��from C,G'' to_�'ft. yards a• 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 properry? ❑Yes [�lo 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. �n `�tc�-lola ��eli F�ri 11 i*� ('p� In� ��1 Licensee Business Name f License or Regishation No. �; �,if 11-3�J—lh �'fied Representa ve Signature Certified Rep.No. Date " 3 4 4 3 0 4 `Ti� ��t"�,g�� LOCAL COPY Name of Person Sealing Well or Boring HE-01434-14 ID#53159 5/13R .. . . . . . . . . .. . .. . :..... ... .._. ... .�.. _ . . ._._.. . . . . ... _. . . . . .. . __.: