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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �� 419 0 <br /> County Name , <br /> WELL AND BORING SEALING RECORD Mennle90 a�Unique WeII No. <br /> • Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Laeva Wenk il not Iviown) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> �' �k,1 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> / <br /> Depth Before Sealing /(�� ft. Original Depth ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 31�39 Farvie�a I.�ne, �rQ� 55391 W LUBORING Measured ❑Estimated Date Measured_'�J���'� <br /> Water-Supply Well ❑Monit.Well ��j r <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 buildings. <br /> N ��u CASINGTYPE(S) <br /> � <br /> --'-- --'------`-- —_'_ ' <br /> ,.,.J teel ❑Plastic ❑Tile ❑Other <br /> ' ' - '-' - '-- � � WELLHEAD COMPLETION <br /> - '- - -'-- -`- - <br /> W � � � � E <br /> __�___ __�,__ _._;_ .__�__ T � Outside: ❑Well House ❑At Grade Inside: [J Basement Offset <br /> I 'e �itless Adapter/Unit ❑Buried ❑Well Pit <br /> " " " ' ❑Buried <br /> ' T S ' ' � ^ ❑Well Pit <br /> p`�"' ❑Other <br /> �1 Mile� pl ❑Other <br /> 0 V7 <br /> PROPERTY OWNER'S NAME/COMPANY NAME � CASING(S) <br /> f i Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if diHerent ihan well location address indica�ed above //. � � <br /> in.from�__ to //Y� ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> 3205 Harbor Lane • -` � <br /> Ply�r�azth, � S��Y7 in.from to ft. []Yes ❑No ❑Yes ❑No ❑Unknawn <br /> in.from to ft ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> i <br /> Well owner's mailing address if diNerent Ihan property owne�'s address indicated above Screen from_ //Y� to � ft. Open HOIe from to ff. <br /> YY�`�- <br /> OBSTFUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris (-1 Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS oa FROM TO Obstructions 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 �Not Present ❑Other <br /> ff <br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists !�Annular Space Grouted with Tremie Pipe �]Casing Perforation/Removal <br /> in.from to ft. ]Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type ot Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes No TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material _ �from�_ to��j&_ ft. yards�_ bags <br /> from to fl. yards bags <br /> _ _ from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES 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 intormation con[ained in this report <br /> is true to the best of my knowledge. <br /> '�on �todala Well Drilling Co,. Inc. 1�i91 <br /> Licensee Businers N�ne i � License or Registration No. <br /> y � <br /> .� r' fj ,, j <br /> _ �;�� r /j' �- �_ <br /> �/Ce�dff resentative Signat e Certified Rep. ate <br /> c �`"' <br /> " ��� ��90 � ,�, <br /> LOCAL COPY `�`'`--�,. ."`' �� � j ✓`i-.S'�`, <br /> Name of Person Sealing Well or Boring <br /> HE-01434-14 ID#53159 .. 5n3R <br />