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A111NNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring � �
<br /> WELL OR BQRING LOCA710N...-' t Sealing No. H
<br /> �o��,v Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
<br /> � � Minnesota Statutes,Chapter 1031 or W-series No. ,
<br /> ��aeve eiane u no�Nnow�)
<br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
<br /> arono 117 23 08 3—�0(�4 '� � 1 J` � �j 7 "
<br /> ,
<br /> GPS Latitude degrees minutes seconds Depth Before Sealing �� _ft. Original Depth _ft �
<br /> LOCATION: Longitude degrees__ minutes__ seconds pQUIFER(S) STATIC WATER LEVEL
<br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location Single Aquifer ❑Multiaquifer �sf �f � ✓
<br /> WELUBORING ,�nJ Measured ❑Estimated Date Measurec��� �/
<br /> vf7Water-Supply Well '�Monit.Well �
<br /> Show exact location of well or boring Sketch map of well or boring �C 7
<br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other �:Z ft. �below �above land surface
<br /> " N lines,roads,and buildings.rj� CASING TYPE(S)
<br /> il � � � �
<br /> � � Steel ,����..Plastic n Tile ❑Other
<br /> s � , � � 1
<br /> WELLHEAD COMPLETION
<br /> W - ,------- --,-----,-- E T �� � � - -
<br /> -;- ; ' ;
<br /> Outside: ; -��Well House �]At Grade Inside:�Basement Offset
<br /> : � � � � (�
<br /> , , , , 'h nniie ,l rtless A p dUnit U Buried ❑Well Pit
<br /> - , , , , � . [�P� da te
<br /> --�-----�-- ---�-- --%- �,. �,
<br /> � ❑Buried
<br /> ' � 5 � ' [ ]Well Pit
<br /> ��� » � ❑Other
<br /> �1 Mile� ��-�' � [�Other
<br /> PROTP,E�RTY OWvN_ER'S NAME/COMPANY NAME CASING(S)
<br /> ••■� i'iiin�rren Diameter � Depth / Set in oversize hole? Annular space initially grouled?
<br /> Properry owner's mailing address if different than well location address indicated above �� � to 1 � �
<br /> �__in.from !�'�U ft. ❑Yes �]No ��j Yes i�No ]Unknown
<br /> in.from to ft. ��Yes ❑No ❑Yes (_�No J Unknown
<br /> _in.from _ to ft. j_;Yes ❑No ❑Yes ❑No ❑Unknown
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE �
<br /> /
<br /> Well owner's mailing address it different ihan property owr,er's adtlress indicated above SCfeen from��_to ��ft. Open Hole from__ _to ft.
<br /> OBSTRUCTIONS
<br /> Rods/Drop Pipe �Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
<br /> Type of Obstructions(Describe) ,r/�/�L� Jf�� Q' ��1
<br /> GEOLOGICAL MATERIAL COLOR HAHDNESS OR FROM TO Obstructions removed? �Yes j�_J No Describe
<br /> PORMATION —
<br /> � PUMP
<br /> If not known,indicate estimated formation log from nearby well or boring. �f` /�um�
<br /> TYPe " 'f
<br /> � � � l� �� � � Removed ❑Not resent '._'�,Other
<br /> � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: „�
<br /> _ J No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
<br /> _in.from to ft. ❑Perforated ❑Removed s
<br /> k
<br /> in.from to ft. ❑Perforated ❑Removed
<br /> Type of Perforator
<br /> ��,_j Other
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> � r t
<br /> Grouting Materi�L�� (._�!/P_��from � to �2 ft. _ 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 RF_GISTERED 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 ihe best of my knowledge.
<br /> Don 5todola tdell Dcillin,�C__e.;InC. 1691
<br /> Contractor Business Name License or Registration No.
<br /> i / / _
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<br /> _�- `�` '� /
<br /> _ — - ------
<br /> C f' . Sren at ve 'igna, re� Certilied Rep.No. Date
<br /> '! H A ^ A ,.,` ,_._,,.� ..?_., �,..,.<, ,.,��...-
<br /> LOCAL COPY J�}�O 7 j(
<br /> i� �r y Name ol Person Sealing Well or Boring
<br /> HE-01434-09 IC#140-0423 � s/osa
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