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WEIL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H ��.� 7 4 4 County Name WELL AND BORING SEALING RECORD Mennlego a�Unique Well No. ?T��j�n Minnesota Statutes,Chapter 1031 °ed�Nse�ies No_ Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed bron� 117 ?3 11 "�' ','S., .,1, GPS LOCATION—decimal degrees(to tour decimal places) � Latitude Longitude Depth Before Sealing ��2 ft. Original Depth tt. A�UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer 1�7n `7[`�C��rAt ts nr�int �C�� '�E !}Pl� �5�� W�EL'L"/BORING �Measured ❑Estimated Date Measured'�� ,��"� �yvvater-Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or boring in section grid with"X" location,showing property �'Env.Bore Hole ❑Other_ 3�ft. �below ❑above land surface lines,roads,and buildings. N (��. CASING TYPE(S) 1 J Steel ❑Plastic ❑Tile ❑Other --'---—y-- --`-----t-- ��:J � WELLHEAD COMPLETION W : ; ; : ET �. , __�___ __�___ __�__ ___;__ -.,�, � Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset � ; ; � ; 'h nniie less A p r/Unit ❑Buried ❑Well Pit � `\ --- � �Pit da te --:--- --r-------- ---=-- 1 � o � � ❑Buried S ' ' ❑Well Pit ; �rniie� ❑Other ❑�1her PFOPERTY OWNER'S NAME/COMPANY NAME CASING(S) t-T + Diameter Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above �� �__in.from�. to.��_ft. ❑Yes �No ❑Yes ❑No ❑Unknown bQ2E� Pills�bty AvP � in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown �tinnep�oli.s, t�+t 5544�..4�- _ ._ � �::�.� in.trom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME � � ` ' . ,.; � SCREEN/OPEN HOLE �-�,�,;�. ��, � � s 1 Well owner's mailing address if different than properry owner's address indicated above Screen frofi��__t0��_ft. Open Hole ffom to ft. �^°'-�� ' ' , � � � '_� � � OBSTRUCTIONS ',�-`.. . . � ., � ,,,��/// �Rods/Drop Pipe ❑Check Valve(s) (]Debris ❑Fill ❑No Obstruction ..r Type of Obstructions(Describe) �/�/��f�' g �� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes []Na Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. � Type � �r Removed ❑N Present ❑Other METHOD USEDTO 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. ❑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.) t r Grouting Material/�/�C�Q��I�LAfT•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? U 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. �on Stcvlola We1lPrilling Co., Inc. 1fi91 Licensee Busine�s Name License or Registration No. _ ,� %,��_ �= //- /- l� � �. rHliptl.Aep esentat ve 3igAatur " Certified Rep.No. Date li `� � � � ��, ,�-f�.a.u-�- LOCAL COPY e}'�� y �� Name of Person Sealing Well or Boring '" HE-01434-14 ID#53159 ._ 5n3R