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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring F„� ��['��(1� <br /> Counry Name <br /> WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. �r �"� <br /> Minnesota Statutes,Cha ter 103I or W-series No. <br /> P i�ea�e ma�k��o�k�ow�� <br /> ' Township a Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> 1 <br /> /< /< /< (Q �v� {Q ' <br /> 1 � % <br /> t <br /> GPS Latitude degrees minutes_______ seconds Depth Betore Sealing � �� ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds UIFER(S) STATIC WATER LEVEL <br /> ,' Numerical Street Address or Fire Number and City of ell or Boring Location ,Single Aquifer ❑Multiaquifei �/� (�/'�f/ <br /> � Measured Estimated Date Measured M� I?1'r <br /> �'j rb/�D WELL/BORING � ❑ 7'� <br /> Water-Supply Well ❑Monit.Well � t <br /> Show exact location of well or boring Sketch map of well or boring --�Env.Bore Hole <br /> in section grid with"X." location,showing property � ❑Other �ft. �below ❑above land surface <br /> N ines,r ds,and}�iings. CASING TYPE(S) <br /> f ' , 1 <br /> � ; ; ; ; -y."e5t l 1�. <br /> --�-----�--- --�----•-- <br /> ` scee� []P�astic ❑ri�e []omer <br /> ; ; ; ; `--__...._,, <br /> -- --------- -- ------- � WELLHEAD COMPLETION <br /> : W E <br /> ;__ _ _ T �� Outside: ❑Well House �_;At Grade Inside: �Basement Offset ' <br /> � � <br /> , , , 'h Miie - ` itless A p r/Unrt �_.I Buried ,�Well Pit <br /> , , , , � ���—�- �]P� da te � <br /> --�-----�--- ---%----+-- •_„�� �J Buried ' <br /> � � S � � <br /> ��)"` ❑Well Pit <br /> �1 Mile <br /> � ❑Other ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diastetgr� ' Depth /�' � Set in oversize hole? Annular space initially grouted? <br /> Prope n ma i A� different Ihan well location address indicated above '� in.from �✓ to�ft. ❑Yes �f No ❑Yes ❑No ❑Unknown <br /> �iTJL n�� nCilt R� in.fram to ft. �J Yes �.-_]No ❑Yes ❑No ❑Unknown <br /> deephaven, M� �5331 <br /> in.from to ft. ❑Yes []No ❑Yes ❑No ]Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above SCfeen from CJ ' to j �� ,ft. Open Hole from to ____ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> r <br /> Type of Obstructions(Describe).�f�,/�.�'�� ��/�'� ¢' �J'�r <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obsiructions removed? �Yes ❑No Describe <br /> FOHMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> . a TYPe <br /> �c <br /> U Removed �ot 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 s <br /> in.from_ b ft. ❑Perforated [_)Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag ot cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material ���1`��N�'f o_�_ to_�s.lZ ft. yards �+O ba s <br /> 9 <br /> from to ft. yards bags <br /> - from to ft. yards bags <br /> i <br /> OTHER WELLS AND BORINGS <br /> qEMARKS,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 /> Dan Stoclola WeTI Drillin� Co., Inc. 169I <br /> Licensee Business Name � --- License or Registration No. <br /> _ e�,�� �-- /1- �U <br /> C Yf t'e 7i a�v ignatur�� Certified Rep.No. Date <br /> H `'� ,_._ '.,,�;�Y=.,a.:x�,+�� <br /> LOCA!CCPY 2 9 O O a 2 Name of Person Sealing Well or Boring � <br /> HE-0143412 IC#140-0423 siosR <br /> it <br />