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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 2 617 3 2 ` <br /> WELL OR BORING LOCATION Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. .. � <br /> Minnesota Statutes, Chanter 103/ or W-series No. <br /> �p�� � . ~ (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Consiructed <br /> OL'�Q 117 �3 �7 Z��t�' L j�! G�/ <br /> i <br /> GPS Latitude __�� degrees minutes seconds Depth Before Sealing� ft. Originai Depth ft. <br /> LOCATION: Longitude degrees_ minutes _ seconds A �FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Loca�ion . Single Aquifer ❑Multiaquifer �� A��� . <br /> WELL/BORING .Measured IJ Estimated Date Measure �� <br /> Water-Supply Well ❑Monit.Well � <br /> Show exact Iocation of well or boring Sketch map of well or boring I 1 Env.Bore Hole Other �fL �elow above land surface <br /> in section grid with'X" location,showing property --- ❑ ❑ <br /> N f� �in�es,r�ads/and,, �Idings. CASINGTYPE(S) <br /> fi' <br /> J <br /> \y �Steel �_�,Plastic ❑Tile ❑Other_ _ <br /> '` I I ; I • ��� �' <br /> ' --'------�-- ---�-----'-- '� WELLHEAD COMPLETION �� <br /> . W ; ; ; : ET <br /> � __;____I__ __�__ ___:__ Outside: ]Well House ❑At Grade Inside: ❑Basement Offset � <br /> ° , , , , Mile itless A p r/Und ❑Buried ��Well Pit ,� <br /> �� �P� da te ' <br /> ------ ------ ---�-- ---:- 1 <br /> ❑Buried + <br /> 5 ❑Well Pit <br /> f]Other ___ <br /> �i M�ie� u Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � Diarr�te�r� �/ Dep A Set in oversize hole? Annular sp2ce initially grouted? <br /> Property owners mailing a ress i tlitlerent than well iocation address indicated above � � <br /> -r in.trom to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> � in.from to ft. []Yes �'i No ❑Yes ❑No ❑Unknown <br /> in.from_ to ft. [�Yes ❑No ❑Yes ❑No �..�Unknown <br /> �i- WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> f {� � <br /> �� Well owner's mailing address if diRerent than property owrer's address indicated above SCreen from___�to C✓� ft. Open Hole ffom to_ ____._ft. <br /> OBSTRUCTIONS <br /> '� ��Rods/Drop Pipe ❑Check Valve(s) [_]Debris r]Fill �No Obstruction <br /> a <br /> g Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS 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 /> � <br /> TyPe------ <br /> �-� �-'""-�-� '--^� �J� ❑Removed I�Vot Present ❑Other <br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �.No Annular Space Exists i]Annular Space Grouted with Tremie Pipe !]Casing Perforation/Removal <br /> in.from to ____ft. ❑Perforated ❑Removed r, <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 y/{' y'rl� <br /> Grouting Materia��=/"�� �����'� from V to �/�ft._ __ yards C.� 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 <br /> is true to the best of my knowledge. <br /> DOA SC0C1018 W�*II DCIZZ�t1�C0.� ZLiC. ],_(j91------ <br /> Contraclor Business Name /'� License or Registration No. <br /> � <br /> � �t, ., ��" _,,,,,: {j � <br /> (. er� ep`resentative Signature � � Certified Rep.No. Date <br /> { � /,_,.... �� <br /> LOCAL COPY H Z 617 3 Z ` { � - r� r� <br /> Name of Person Sealing Well or Boring <br /> HE-01434-09 IC#140-0423 ..� siosa <br />