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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 4 4 3 0 4 County Name WELL AND BORING SEALING RECORD M nnleso a�Unique Well No. Minnesota Statutes,Cha ter 103I or W-series No. P (Leeve blenM II no�known) tt Townsfiip rfie Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boiing Constructed �'mn� 117 23 !�� '`�; 9R `�:� 2 GPS LOCATION—decimal degrees(to four decimal places) (� / Depth Betore Sealing G.�� ft. Original Depth ft. Latitude Longitude IFER(S) STATIC WATER LEVEL N or Boring Location Single Aquifer � �Multiaquifer �/ � yUEyUBORING �Measured ❑Estimated Date Measuredyr,,��r � .� �� '�oater-Supply Well ❑Monit.Well / Show exact location of�dell or borin Sketch ap of well or boring in section grid with"X° locatio ,showing property �_�Env.Bore Hole ❑Other �ft. �,below ❑above land surface line oads,and buildings. -:i CASING TYPE(S) -1 . . �;._J�3.z� -''-"-'�— ---`-----'— � . �i I�t'Steel �]Plastic ❑Tile ❑Other , � , , � T\ --i-----.— ---`-----t-- WELLHEAD COMPLETION � � � � � ,-�_'�"— W : ; ; � ET �/ � � � � Outside: ❑Well House ❑At Grade Inside: IR Basement Offset . -- -- - ------- -- r-1 - -- -- ' � ; ; , , M�ie itless A p r/Unit ❑ uried ell Pit � ❑P' da te B �W --�-----T— ---�-- --�- hI s J� ❑Buried ,:. S 1 �T ❑Well Pit ❑Other �1 Mile� ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) `�,�,j.`�=� �:`„'�..'7E7'-'?t 2 il 1 Diameter � Depth / Set in oversize hole? Annular space initially grouted? P�operty owner's mailing address if different than well location address indicated above �� /� �.in.from �O to ft. ❑Yes �lo ❑Yes ❑No ❑Unknown �'�S� T;TP$t Kjll P� in.from to ft. []Yes ❑No ❑Yes ❑No ❑Unknown [�'atert�an, M�T 553"" 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 Screen from_�to�ft. Open Hole from t0 ft. OBSTRUCTIONS �Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill [ �No Obstruction Type of Obstructions(Describe)1�w�x �� ' �� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? s ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. Type ,�,/ �f h �? ❑Removed UCNot Present ❑Other r1 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �lo 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.) _ /�� ry / � Grouting Material/��/7�T��from � to� ft. yards_` 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? [__l Yes [�o 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. �'icm `�ttxlolt� E'eli �r911 i;-►b C=�; _ Inc- 1'��'1 Licensee Business Name � License or Registration No. r i - �, � 11-�r�-16 f Qerfified Representa ve Signature Certilied Rep.No. Date " 3� ��0 4 .j�� nt�� LOCAL COPY Name ol Person Sealing Well or Boring HE-01434-14 ID#53159 5n3R