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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„+ � <br /> Coui4ty Name � <br /> WELL AND BORING SEALING RECORD Minneso a�Unique Well No. <br /> � iA Minnesota Statutes, Chapter 1031 or W-series No. <br /> (Leave blenk II not knownJ <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> c� 11� 23 � s� s� s� ia �v o <br /> . <br /> GPS Latitude__ degrees _ minutes_____ seconds Depth Before Sealing � ft. Original Depth ft. <br /> LOCATION: Longitude_.__ degrees minutes____ seconds p U FER(S) STATIC WATER LEVEL E <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location , �ngle Aquifer ❑Multiaquifer ` p� <br /> IZC7lJ Li [�� 0� 5539I WELUBORING �leasured ❑Estimated Date Measured ✓��� —y7 <br /> �Vater-Supply Well f—J Monit.Well � <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. �elow ❑above land surface <br /> _ N lines,roads,and buildings. CASING TYPE(S) <br /> ; 1 1 I <br /> __'_____'___ ___`__ ___'__ t <br /> [�teel �lastic [__]Tile ❑Other <br /> ��� <br /> a --�-----�--- ---�-- ---`-- WELLHEAD COMPLETION <br /> W : � ; � ET <br /> : � � _;_____�__ � ��� Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> � � � � <br /> 'h M'ie `ly � �itless Adapter/Unit ❑Buried ❑Well Pit <br /> --.-----� ; ; 1 ,� <br /> r-- ---�-- ---.- <br /> ❑Weil Pit ❑Buried <br /> S ❑Other <br /> �-7 Mile-� �'�._fi� ❑Ofh2f _ <br /> Yr.,��, \. <br /> PROPERTY OWNER'S NAME/COMPANY NAM - CASING(S) <br /> - C Diam�te�� � Dept�� t Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different Ihan well location address indicated above /''� {� <br /> �_in.from�/ to �`v V ft. ❑Yes �o �_.j Yes ❑No ❑Unknown <br /> in.from to R ❑Yes �_�:No ��_'�Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes U No ❑Unknown i <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � t <br /> Well owner's mailing address if ditterent than property owner's address indicated above Screen from �� to /�� ft. Open Hole from to ft. <br /> OBSTRUCTIONS ,�,` <br /> L�Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill I J�10 Obstruction <br /> r- <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes U No Describe <br /> FORMATION <br /> PUMP <br /> If not nown,indicate estima[ed formation log from nearby well or boring. <br /> - , � � TYPe <br /> _'�,Removed j��Vot Present ❑Other <br /> j ... <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �o 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 ben�nite=50 Ibs.) <br /> .�yT f } +� <br /> Grouting Material���`/ �L�� from_� to���ft. yards �,G.bags <br /> a <br /> from_ to ft. yards bags <br /> _._ from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> s <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? [�Yes � o 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 <br /> is true to the best of my knowledge. <br /> l�n Stoclola tiell Drilling Co., Inc. 169I <br /> � __ _ . <br /> __ __ ------ - — <br /> Licensee Business Name License or Registration No. <br /> �f ',_ <br /> . //—/..�� �:� <br /> �. epresentati S�n e �� Certified Rep.No. Date <br /> " _c�����Pv • H 27J�462 � --- � ,..,.. �,..��.� _ <br /> ' �� Name of Person Sealing Well or Boring i ' <br /> _ __ . .-----.—.�_ <br /> HE-01434-11 IC#140-0423 -' tioeR <br />