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WELL OR BORING LOCanON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> �� �� Minnesota Statutes,Chapter f031 or W-series No. <br /> c�w�aerv�n�w a�ow�,� <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> v. v. v. � <br /> GPS Latitude degrees minutes seconds �/ � <br /> LOCATION: Depth Before Sealing l a`x ft. Original Depth fl. <br /> Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> WELL/BORING Measured ❑Estimated <br /> �Water Supply Well ❑Monft.Well � <br /> Show exact location of well or boring Sketch map of well or boring <br /> in seclion grid wfth"X" Ixation,showing property ❑Env.Bore Hole ❑Other �tt. �below ❑above land surface <br /> lines,roads,and buildings. <br /> N ;',! CASING TYPE(S) <br /> 1 � '��_.,=�:�. <br /> -T- -T- -;-- ;-- �... ,��;�\, , �Steel <br /> � ❑Plastic ❑Tile ❑Other <br /> W —�- -�-- -�-- --;-- E `"'�.1�`/ ��^ WELLHEADCOMPLETION <br /> � � � � <br /> � � � � �"�.. Outside: ❑Well House Inside: ❑Basement Offset <br /> -;r- ---- -;-- --i-- � <br /> � 1�^� '�Pitless Adapter/Unit ❑Well Pit <br /> --�- -�-- -i-- --�-- I �' <br /> 1 ❑well Pit ❑Buried <br /> S <br /> �—�"M1°—�' ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME �s CASING(S) <br /> Lakevi.�w Goi f cou�cse �rQ 4T�'$(�� r � � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above � <br /> � in.ffORl�to�G)�ft. ❑Yes IOINo ❑Yes ❑No ❑Unknown <br /> 71� �3Ct�i �lOt£�! F3t W �, <br /> /\..�' p� Gt�7G! in.ffOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> LL .7 �71GW <br /> in.ffOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � <br /> �/�}� � ��, �/ <br /> Wel�owner's mailing address if different than property owner's address indicated above Screen from�.cL t0�ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill �/No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Y2S ❑ NO D@SCfib@ <br /> FORMATION <br /> If rrot known,indicate estimated formation log from nearby well or boring PUMP <br /> Type <br /> ✓ <br /> ❑ Removed f�Vot Present ❑Other <br /> J METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> L�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 of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> / , <br /> Grouting Material���� ���fi�i from�to�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 properry? ❑ Yes o How many? <br /> LICENSED OR REGISTERED CONTHACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best ot my knowledge. <br /> non sc«toz.a wQll T�rillfn��.�. rr,c 27�72 <br /> Contractor Business Name License or Registration No. <br /> , <br /> , ___. <br /> - -� _�' �y :�� <br /> h 'e se ive Sign Date <br /> :. __ �,^'',. <br /> H 2��J�S� % �� .s�.. <br /> LOCALCOPY ' <br /> Name o/Person Sealing Well or Bonng _ <br />