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wELL oR BORING LOCnnON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' � <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. <br /> �� �n Minnesota Statutes,Chapter f031 or W-series No. <br /> ��ve oienk a rwi kno»n) <br /> Toxmship Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> tTrem� 117 2 Ob 4 2 �,. �,. � F � <br /> . <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing � ft. Original Depth ft. <br /> Longdude degrees minutes seconds p IFER(S) STATIC WATER LEVEI. <br /> Numerical Sheet Address or Fire Number and City of Well or Boring Location Single Aqu'rfer ❑Multiaqu'rfer <br /> WELUBORING �Measured ❑Estimated <br /> Water Suppty Well ❑Monit.Well <br /> - Show exact location of well or boring Sketch map of well or boring <br /> in seclion grid with"X" location,showing property ❑Env.Bore Hole ❑Other ft. ❑below ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> - - - - - -- - -- �__�_� <br /> __.._.,—. - `�Steel ❑Plastic ❑Tile ❑O[her <br /> n <br /> W --�- -i-- -i-- --;— E - WELLHEADCOMPLE710N <br /> � � � �,! � <br /> Y � � � Outside: ❑Well House Inside: �asement Offset <br /> -�- -;-- --�— _ <br /> � � � � �� t .lQ_�� <br /> ❑Pitless Adapter/Unit ❑Well Pit <br /> --`- -i-- -i-- --i-- I <br /> � ❑Well Pft ❑Buried <br /> s �, �� � �y <br /> �---i^w—+� , _r;�,,,., ` .?r� ❑s��ed <br /> t <br /> PROPERTY O�*WL�N�ER'S NAME/tCTO..MPANY NAME CASING(S) <br /> � ' .711a� vfn�� Di te�� � Deptli � Set in oversize hole? Annular space initially grouted? <br /> � Properry owner's mailing address'rf diHerent than well location address indicated above <br /> � in.from�to�ft. ❑Yes �lo ❑Yes ❑No ❑Unknown <br /> 9� 88 ��OV� <br /> In.ffOm to ft. ❑Yes ❑No ❑Yes ❑Na ❑Unknown <br /> in.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> - WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> � C , <br /> Well ownei's mailing address if diHerent than property owner's address indicated above Screen from�t0�ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill f�No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑YeS ❑ NO DeSCflbe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> •'� �T TYPe <br /> ��'�' ❑ Removed ot Present ❑Other : <br /> .AETHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> pr No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PerforatioNRemoval <br /> /� <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 /> ,+i � � <br /> Grouting Matenal��'L�� ��///�''��from�to �� 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 REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The infortnation contained in this report is <br /> true to the best of my knowledge. <br /> Tbn Stodola t�ell Drillin;� Co., Inc. Z7I72 <br /> Contractor Business Name License or Registration No. <br /> ''!i ..i J .�-t _ /'�.-'�°'� .�'`�/ J,,,.-.� <br /> , &pfe�eir(ative Signature Date <br /> � ��. ,.. _ . �� - �"�< <�::.��, �..J <br /> LOCAL COPY H ����$� Name o/Person Sealing Well or Bonng <br />