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` WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �O�H i '7 County Name WELL AND BORING SEALING RECORD M nn�egoNa Unique Well No. ��i� Minnesota Statutes,Chapter 1031 or W-series No. (Leave blank�it not knownJ Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed orora 117 23 07 �E �E �Z , GPS Latitude degrees____ minutes seconds Depth Before Sealing__�ft. Original Depth ft. LOCATION: Longitude degrees_____ minutes seconds AQ �FER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location . . ingle Aquifer ❑Multiaquifer t� 1505 North Acm Dr, � 1�.7�.�Y C �'/ELL/BORING �1Qeasured ❑Estimated Date Measured JM��y_ �Nater-Supply Well !_]Monit.Well I Show exact location of weil or boring Sketch map of well or b � C in section grid with"X." location,showing prope .Env.Bore Hole L]Other ��+.._.. ft. �elow ❑above land surface N lines,roads,and building � �� CASING TYPE(S) --'--- --'-- --'-- --'-- 7 j j j j . Steel ❑Plastic ❑Tile �,_';Other � --'--- --�-- ---`-- ---'" �• �Y � � WELLHEAD COMPLETION W � � � � E ,�7 _ ..,,. � � � � T " � Outside: :`�Well House [_J At Grade Inside: ❑Basement Offset ; ------ ------ ---�-- ---*-- ;; , , , , Mile dless A p dUnit ❑Buried ❑Well Pit i� " —�--- --;-- ---;-----;- I 1 �+ _ Buried �P da te `� D ' ' ' ' L \ �]Well Pit S � ❑Other �1 Mile-� .� ❑Oth2f PR/p�P�E�RTY WNE/g' NAME/ PANY AM CASING(S) �++�C�e$I��e�� Diameter � Depth ( Set in oversize hole? Annular space initially grouted? Property owner�s mailing address rf different than well location address indicated above ��in.from � to 1�ft. ❑Yes �No []Yes '��No ❑UnknoWn in.from to ft. ❑Yes ,!Na ❑Yes ❑No ❑Unknown in.from to ft. �J Yes ❑No ❑Yes ❑No ❑Unknown � WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE Well owner's mailing address if diNerent than property owner's address indicated above SCreen from��to�ft. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe U Check Valve(s) ❑Debris � ��Fill �No Obstruction Type of Obstructions(Describe) ____._ __ GEOLOGICAL MATERIAL COLOR HARDNESS OFi FROM TO Obstructions removed? ❑Yes ��; ]No Describe FORMATION PUMP If not known,indicate estimated(ormation log from nearby well or boring. � � �� Type ��Removed �Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE 'z �No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe !�Casing Perforetion/Removal in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator ❑Other _„__ GROUTING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite=50 Ibs.) . wfc �yy! f�/ / /� � Grouting Material r��f/��from V to �� ft. yards��L bags s from to _ ft. yards bags from__ to ft. yards bags OTHER WELLS AND BORINGS r REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING o 0 Other unsealed and unused well or borinr�on property. ��Yes o How many. 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 ta the best of my knowledge. ; non sc�ociola r�ell Drilling co,. Inc. 1691 r�- Licensee Business N e License or Registration No. �-�'' _ � ; �. �-�� !� Ce ied pre entative Signatur Certified Rep.No. Date LOCAL COPY H �0 2 8 7� — {� �'�'r``� — k Name of Person Sealing Well or Boring � HE-01434-12 IC#140-0423 " g�agR