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WELL O�i BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2�5 312 �County Name WELL AND BORING SEALING RECORD Minnego a�Unique Well No. Minnesota Statutes, Chapter 1031 or W-series No. ' (Leeva�lenk�il not knownJ Township a e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �� y �� 1 r� i GPS Latitude degrees minutes seconds Depth Before Sealing ��,'�„ ft. Original Depth ft. LOCATION: Longitude degrees minutes seconds A IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and Ciry of Well or Boring Location , ingle Aquifer [�Multiaquifer /� A W LL/BORING I�,Measured �1 Estimated Date Measured S�f't� !1� � � Water-Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or bo� � in section grid with"X" location,showing pro er - . ❑Env.Bore Hole ❑Other_.___ �ft. �]below ❑above land surtace N lines,roads,and b i in � _, CASING TYPE(S) � --'-----'--- --L----- -- " ' � � � � I I t I th `� --'--- --;--- ---� —`_ `�`J ELLHEA ]P as ic ❑Ti e ------- ��Q1 te [ ❑O er � f W D COMPLETION W , � � � E �� I__ ___;_ � T `� � Outside: ❑Well House �t Grade Inside: [�Basement Offset , --- - - - ---- -- � i - �--' __ � .: ; i ' : 11e 0 �. itless A p r/Und ❑ uried (_,Well Pd a � � 1M O !]P da te B s '�� (]Well Pit i-�Buried �--t Miie—� ❑Other ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) � . Di�ayme�r �� / Depth t Set in oversize hole? Annular space initially grouted? Properry owner's mailing address if diflerent than well location address indicated above / '? in.from to ft. Yes No Yes r No � � �._y� o � [] �j ❑ �] �J Unknown in.from to ft. ❑Yes [l�:No ❑Yes ❑No []Unknown in.from__ to ft. ❑Yes ❑No ❑Yes ❑Na ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � r � � Well owner's mailing address if tlifferent than properry owner's address indicated above SCreen from � �� to � � � ft. Open Hole ffom to ft. � OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �o Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARONEss oR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION If not known,indicate estimated formation log from nearby well or boring. PUMP � dilit 0 �� Type ❑Removed �Not Present ❑Other i� j METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: A� No Annular Space Exists []Annular Space Grouted with Tremie Pipe [_I Casing Pertorafion/Removal f in.from to ft. []Perforated [J Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator U Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) N`�j��,�� /',r /`�� i Grouting Material from__ .� tof 2i`;_ ft. yards�_ bags _ irom to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? [j Yes o How many7 LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report ��- is true to the best of my knowledge. tlnn �+tOdO�8-�� 13��CA.� TA�. �$�� L�censee Busness Name icense or Registrahon No. J - io-2-o� i�d epresentative Signature - Certified Rep.No. Date 2 fi 5 312 _'� '�`°"�' LOCALCOPY H Name of Person Sealing Well or Boring HE-01434-70 IC#140-0423 slo7a �