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W6LL�R BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„� � �C �o Q
<br /> � County Name
<br /> WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. �, J �
<br /> Minnesota Statutes,Chapter f031 or W-series No.
<br /> ;r �
<br /> (Leave blank�il n0�known]
<br /> Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed
<br /> f� c 7 7 ��'." �€? �7 �l� 1.� -
<br /> �
<br /> GPS Latitude degrees minutes seconds Depth Before Sealing__ ��! ft. Original Depth____ ft.
<br /> LOCATION: Longitude _ degrees__ minutes seconds
<br /> �IPER(S) STATIC WATER LEVEL
<br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer �_]Multiaquifer /�
<br /> r � •t 1 ?� r �i(vleasured �]Estimated Date Measured `�/��_ '/�Y
<br /> � �� !�C� ' �`ar'r"; ,�� �C�€'�O i�i`�,ti LUBORING
<br /> Water-Supply Well ����;Monit.Well /�
<br /> Show exact location of well or boring Sketch map of well or boring .-,
<br /> in section grid with"X" location,showing property ��._�Env.Bore Hole (.]Other �U fl. '�below ❑above land surface
<br /> N __, }��•, FN�e�,roads,and buildin�. CASING TYPE(S)
<br /> .��,s. �..0
<br /> --�-----�--- ---�-----�--
<br /> . :� s�eei i_�Piast�o []rie Ll ome�
<br /> ,
<br /> ''"'""-'"-' ---`" '--�-- WELLHEAD COMPLETION
<br /> W ; : : ; ET �_
<br /> �_
<br /> - � � � � � Outside: [;Well House ❑At Grade inside: �f Basement Offset
<br /> �. -'�-----�--- --�-- --%-
<br /> , , ; ; ,
<br /> � '�e �+ �Pitless Adapter/Unit ❑Buried ❑Well Pit
<br /> --;-----�--- --�-- --�- Well Pit
<br /> � (.f Buried
<br /> ; ; S ; ; �v� ❑
<br /> ^-+.., � Other
<br /> ��Mite� �'�"'�--,�„_, ❑Other
<br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
<br /> .; .� A •lr Diamet�� Depth` � Set in oversize hole? Annular space initially grouted? '
<br /> Property owner's mailing address it diHerent than well location address indicated above / - '
<br /> _�_in.irom�� to ��� ft. ❑Yes �Na U Yes �__f No ; ]Unknown
<br /> in.from to ft. ❑Yes j]No ❑Yes ❑No �..i Unknown
<br /> _in.from to ft. ❑Yes ❑No ❑Yes I No �,Unknown
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
<br /> r7 �
<br /> ��� / ,
<br /> Well owner's mailing address it diflerent than property owner's address indicated above SCreen from t0 /G/_R. Open Hole ffom to fL y
<br /> - OBSTRUCTIONS ��
<br /> ❑Rods/Drop Pipe ❑Check Valve(s) [j Debris ��Fill {�Vo Obstruction
<br /> Type of Obstructions(Describe) _
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obshuctions removed? [�Yes �J�No Describe
<br /> FORMATION
<br /> PUMP
<br /> If not known,indicate estimated formation log from nearby well or boring.
<br /> � � j TYPe -- -- --
<br /> �f�r r4�� I I 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 [i Removed
<br /> in.from __ _to __ ft. ❑Perforated ��J Removed
<br /> Type ot Perforator
<br /> ❑Other
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> �f i
<br /> a� Grouting Material/ULlt/ ��I�f�f.{� from�_ to/(.•�/ 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 weli 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 /> �on "tcxlola ��:�ell �rillin�; Co., Ia�c. I�,'?1
<br /> Licensee Businesg'Na�rfe _,` . - t License or Registration No.
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<br /> lL�erti/ie epreserrtative Signatwe�� �� �� � Certified Rep.No. Date
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<br /> H � � �g a� �..��. � �.�,,.� ;
<br /> IOCAL COPY � � Name of Person Sealing Well or Bor%ng �
<br /> HE-01434-13 IC#140-0423 " sn2a
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