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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„I '� /� �'i �� County Name WELL AND BORING SEALING RECORD Minnle90 a�Unique Well No. `� '�� `` Minnesota Statutes, Cha ter 1031 or W-series No. ��n P iea�a eia�k�i�o�k�ow�,� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Ornno 11� 23 3Q S'� NW gF .:;;1 �o :�� =: GPS LOCATION- decimal degrees(to four decimal places) Depth Before Sealing � �� fl. Original Depth ft. Latitude __.__ Longitude _ A�UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location � Single Aquifer � -'�Multiaquifer ) 1�N� iRUl� �$� iCiis Qr«� 5S35b �"�ELVBORWG �1 Measured [ ]Estimated Date Measured ,Jti__�_ ��J I�Water-Supply Well j�Monit.Well Show exact location of well or boring Sketch map of well or boring L� in section grid with"X" location,showing property '�� '�Env.Bore Hole ❑Other____.__ ft ,-�.below ,- ��above land surface N �� - ? lines,roads,and buildings. CASINGTYPE(S) � � � � * � � � � --'--- --'-- ---`-- '-- --'--- --;--- ---`-- ---'-- k ELLHEAD COMPLETION ile � th --- --___..._-----__-._----._- .t ,f'r � � �P [ J T ��O er 7 y W W E ��`� •,��1� _ � __;_ _,___ __;__ _ _; _ T ` � Outside: (__I Well House �.�At Grade Inside: ��,_I Basement Offset � , , , , ' Miie "� itless A p r/Und �_]Buried ]Well Pit � P da te --.-- --;--- --.-- -:-- 1 ��Buried ' ' ' ' 'i� U Well Pit S ��.t ',�Other �t nnlie� [�Other PROPERTY OWNER'S NAME/COMPANY NAME CASiNG(S) +.�t�Je Persian Diameter Depth Set in oversize hole? Annular space initially grouted? Property owners mailing address if diflerenl ihan well location address indicated above � in.ffom f �� to f�� ft. �...J Yes ��No �_]Yes '�No I,J�Unknawn in.from to ft. � J Yes � �No [�Yes ❑No ❑Unknown _ in.from to ft. ❑Yes �.J No ❑Yes �No '�Unknown WELL OWNERS NAME/COMPANY NAME SCREEWOPEN HOLE �, / =�� Well owner's mailing address if diflerent than property owner's address indicated above Screen from__ %'- c'�l to f �.J ft. Open Hole from_________to _ _ ft. OBSTRUCTIONS '.�.!Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �J No Obstruction !' .. � Type of Obsiructions(Describe)_ 4 _ _ -=�-- GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �� Yes [__�No Describe_ FOFMATION PUMP , If not known,indicate estimated formation log from nearby well or boring. f� j TYPe---•._...� ,.-Y.�_,r��,d,.,• �1 w�s�.,., — ` ��Removed �_]Not Present ]Other ____ ___ _ _ __ __.__ METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �y,No Annular Space Exists �. .�Annular Space Grouted with Tremie Pipe [.�Casing Perforation/Removal in.from___._________ _to_____.____ft. �Perforated [�Removed in.from to ft. U Perforated [i Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? �,.-�Yes '�No TN#___ _ GROUTING MATERIAL(S) (One bag oT cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material/`�'-�-^ � r�i,..�.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? �,..Yes ._ 'No How many?_ _ , ___ LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in acwrdance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best ot my knowledge. Don Stcxlals WeII t�tillir� Co., Inc. 1b91 Licensee Business N e t � License oi Registration No. J,- � '� � . �, .. � r.� a �._".�`.� 'i � restntati e Sigr(g r Certified Rep.No. Date �� � _.� - �. �......_. LOCAL COPY H 3��Q� - - —- � 1 "� f _ � 't'y"''—' C,,� n t .��--- --___ ---- v Name of Person Sealing Well or Boring HE-01434-14 IC#140-0423 5n3R