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. • <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I �ij���� <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. C <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> c�ea�e aa�a n�a�� <br /> a <br /> Township Na e Township No. Range No. Section No. Fraction(sm-►Ig) Date Sealed Date Well or Boring Co�structed <br /> o�«� i�� 3 4 �,. �,. � <br /> GPS Latitude degrees minutes seconds � � <br /> LOCATION: Depth Betore Sealing � ft. Original Depth ft. <br /> Longitude degrees minutes seconds qqUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> WELUBORING Measured ❑Estimated <br /> Water Supply Well ❑Monit.Well <br /> Show exac loca ion o we or ring Sketc map of well or boring + *�..1 <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other �ft. �below ❑above land surface <br /> �ines,roads,and buildings. <br /> .� N _..__..__........____._...�_..._.,._,_._}� CASINGTYPE(S) . <br /> Steel ❑Plastic ❑Tile ❑Other <br /> �- -�-- -� - - � WELLHEAD COMPLETION <br /> W � E � ,. <br /> � `(}, Outside: ❑Well House Inside: ❑Basement Offset <br /> -'r- --;-- -;-- --i-- �}! <br /> �^"b �j Pitless Adapter/Unit ❑Well Pit <br /> —�- -�-- -i-- --i-- I <br /> � ❑Well Pit ❑Buried <br /> h S <br /> �'—�nM1°—�`� ❑Buried <br /> 1 <br /> S <br /> PROPERTY OWNER'S NAME/COMPAN NAME ` CASING(S) <br /> Diam t�r DepM � Set in oversize hole? Annular space initially grouted? <br /> Properry owner's mailing address if different than well location address indicated above <br /> i�.from�_ t0��ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> s <br /> in.f�Om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ffOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � <br /> i <br /> Well owner's mailing address if different Man property owners address indicated above SCf@2n ffOm�_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)�/�S,L�`��/��L'Q. f[e��' <br /> r/ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM 70 Obstructions removed? Yes ❑ No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well oi boring PUMP <br /> Type C f� 1 <br /> ( <br /> `�Removed ❑ Not Pre ent ❑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 hentonite=50 Ibs.) <br /> /� ( <br /> GroutingMaterial/(���������f�mlLto�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 information contained in this report is <br /> true to the best of my knowledge. <br /> Dor� Stvdala t�11 nrillin� Co., Inc. 27172 <br /> Contractor Business ame License or Registration No. <br /> �' <br /> � `� Ni � �i <br /> u ze e e �ve Signa ure Date � <br /> ,.� r ��.-t' t'.�...�5'+`..' <br /> LOCAL COPY H 2 2 6 i ,5 6 Name of Person Sealing Well or Boring � ��, `5 <br />