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. . f . . . . . . . . . _ . . , . _ <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �Q�(�O� <br /> _ WELLORBORINGIOCATION WELL AND BORING SEALING RECORD Minnesoa�UniqueWellNo. v V <br /> County Name <br /> �g�/� Minnesota Statutes,Chanter 1031 or W-series No. <br /> ili Y (Leave blank i nol known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �� <br /> Orac� 117 23 i I�J 1�►T 1�B d <br /> GPS Latitude_ degrees____ minutes__ seconds Depth Before Sealing ��� , ft. Original Depth ft. <br /> LOCATION: Longitude__ degrees___ minutes_ seconds QUIFER(S) STATIC WATER LEVEL <br /> Numerical Sheet Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �^�t �� <br /> 860 North Arm Ds VLVLA�r SS�{ W �UBORING Measured ❑Estimated Date Measure I"�! �"' _ <br /> � Water-Supply Well ❑Monit.Well t � <br /> i Show exact location of well or boring * Sketch map of well or boring �Env.Bore Hole Q <br /> �_ in section grid with"X." � locatio�,showing property �� �]Other V` ft. �below ❑above land surface <br /> N `� Iines,Ybads,and buildings. CASING TYPE(S) <br /> � � <br /> .. --'--- --i----`-' --'- � <br /> � � teel ❑Plastic ❑Tile ❑Other <br /> ,� --1--- --;------;-----`-- y,� WELLHEAD COMPLETION ..�� <br /> ;. W � I f 1 E �', . <br /> �� � � _;__ __r T� Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset b <br /> ___ _____ ��� �Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> 1 ❑ ❑Buried <br /> S Well Pit <br /> ❑Other <br /> �1 Mile—� L��Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � . � Diarr��q � De� Set in oversize hole? Annular space initialty grouted? <br /> Property owner's mailing address if diflerent than well location address indicated above �/ � <br /> I in.irom O t� ft. ❑Yes �No �J Yes ❑No ❑Unknown <br /> in.trom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.trom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � � <br /> Well owner's mailing address if diflerent than property owner's address indicated above Scfeen ffom��_to���ft. Open Hole ffom_. , to ft. <br /> OBSTRUCTIONS <br /> ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HAaDNEss OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> � St/` TYPe <br /> t---�- ".) f �;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 ben�nite=50 Ibs.) <br /> � <br /> 9 I!-�'�! �J�'�-JIr `,^' Y 9 <br /> Groutin Materia om to._��,�ft. ards��_ ba s <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,OIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �]Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATfON <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 /> Licensee usme s a e ! � e or Registration No. <br /> /," <br /> � C% /%'_ /�"J <br />� �d re entative Sigriat e � Certified Rep.No. Date <br /> LOCAL COPY H �V�O O� '`\�� ' �--4 _J�.S,�,,.�y'���.� <br /> Name of Person Sealing We/l or Boring <br /> 1 <br /> HE-01434-11 IC#140-0423 � voaa <br />�._-.�..:...._.... �.. .-_ ..,.: ._ ....,..��. . .-t., .. .� .. . , _ <br />