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` WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H ���O�a <br /> i County Name <br /> WELL AND BORING SEALING RECORD Minnlesota Unique Well No. " <br /> i ��i� Minnesota Statutes,Chapter 1031 0������ <br /> � <br /> � Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Bonng Constmcted <br /> nroc� I I8 23 26 3�7 �,. O � t3�u� C�'� <br /> . g� • <br /> GPS Latitude degrees minutes seconds Depth Before Sealing �� tt. Original Deptti ft. <br /> LOCATION: tt <br /> Longitude degrees minutes seconds �UIFER(S) STATC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquiter ❑Multiaquffer <br /> � is4o � B�� �rQ� 5��j WELUBORING Measured ❑Estimated <br /> � Water Supply Well ❑Monit.Well � r <br /> Show exact location of well or boring Sketch map of well or boring �j <br /> in section grid wiUi"X" location,showing property ❑Env.Bore Hole ❑O[her �`� ft. �(bebw ❑above land surface <br /> lines,roads,and buildings. <br /> /� <br /> N CASING TYPE(S) <br /> �J Steel ❑Plastic ❑Tile ❑Other <br /> W —�- - - - -- --i-- E �+� WELLHEAD COMPLEIION <br /> � Outside: ❑Well House Inside: ❑Basemerrt Oflset <br /> _Y_ ____ _l__ __i__ <br /> � �� �` �Pitless Adapter/Unit ❑Well Pit <br /> --�- -�-- -i-- --i-- I A`�'}L <br /> 1 ❑Well Pit ❑Buried <br /> S <br /> �'—""r°�' -� i„�� ❑Buned <br /> 4..*5 i..-d' �,�/:.�--.�. ',..� <br /> QFjOP O�E���A�/�OMP4INY NAME �, CASING(S) <br /> 1'� � 4 �i $2�1y Diameter DepUi � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if dilferent than well location address indicated above � /� <br /> in.ffOm � t0�_ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> : 1540 Long Lai�. Blvr� <br /> � �/i.�R�4+: �9I�T 55356 in.f�om to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> ; <br /> ir1.f�Om to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> ' WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> . <br /> t <br /> Well owner's mailing address if difFerent ihan property owners address indicated above Screen from�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 MA7ERIAL COLOR HARDNESS OR FROM 70 Obstructions removed? ❑Yes ❑ No Describe <br /> FORMATION <br /> H not krawn,indica[e estimated formation log from nearby well or boring PUMP <br /> '_ � �� TYPe <br /> N <br /> ❑ Removed � Not Present ❑Other <br /> METHOD USED TO 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 of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of beMonite=501bs.) <br /> t <br /> Grouting Matenal������'1"� from�to��R. yards � bags <br /> from to ft. 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 information conTained in this report is <br /> true to the best of my knowledge. <br /> DOil StClf�lA W��.�. �L'�Z�.�['i� {"A.i �flC. 2�.7z <br /> Contractor Business Name License or Registratlon No. <br /> .-� �� � `�� E' <br /> A n p eSefi a Ye Siyfi r ` Date � <br /> , _� : <br /> H 2 3 4�2 8 `����„ . � _.�,�,..._ � <br /> LOCALCOPV " � � <br /> Name of Person Sealing Well or Boring <br />