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WELL OR ORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �H 3 0 515 i ` County Nam� WELL AND BORING SEALING RECORD Minn'e90 a�Unique Well Na �� % �j � t Minnesota Statutes,Cha ter 1031 or W-series No. �nCLiLlGpl� p I�eave oiana e noi knownl _ Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Ocor� 117 23 09 9$ 1� '- �,� GPS Latitude degrees minutes . seconds Depth Before Sealin / g �t2, ft. OriginalDepth_ ________ft. LOCATION: Longitude degrees minutes _ seconds AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location '. .Single Aquifer ❑Multiaquifer c y r1� WE LIBORING �_�easured I J Estimated Date Measured_V�_�I.__.__ 2J�� rt[1 �� D�� Orana 55391 '�Water-Supply Well ❑Monit.Well Show exact bcation of well or boring Sketch map of well or boring � ' �,/ in section grid with��X." location,showing property __i Env.Bore Hole ❑Other � ft ',�►!V�elow �,_j above land surface N li s, ,and l�dR�fpg/s`.. �CASING TYPE(S) i ��•.,� "'-__'-- --`-- --`- � I�teel ❑Plas[ic ��Tile ❑Other � --''-''-�"" "`-- ---�-- � WELLHEAD COMPLETION ` W 1 i__ ___�__ ___�__ E TMile �. ' _ �_.___,_ Outside: [�Well House ❑At Grade Inside: ❑Basement Offset �� ' � � � I�itless Adapter/Unit I� uried _ ell Pit � B �W ; --.-----:----�-----:-- 1 � ❑Buried S �y,11 ❑Well Pit ? ' f ' �t" ❑Other �-1 Mile� �_.I Other PRlO�PERTY OWNER��S�N,A�MEj�COMPANY NAME CASING(S) i�[[Rl� +JGJ�lii1 Diame er � Depth � Set in oversize hole? Annular space initially grouted? Property owner�s mailing adtlrecs If dllferent�han well location address indicated above ��. r� �_m.from_�_ to_��ft. ;]Yes i o �Yes ❑No ❑Unknown _in.from to ft �_]Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. []Yes ❑No ❑Yes [j No �`J Unknown WELL OWNER'S NAME/COMPANY NAME SCREENIOPEN HOLE f � Well owner's mailing address if different ihan property owner's address indicated above ScreBn from_�__to_.�,_��_,_ft. Open Hole from to ft. OBSTRUCTIONS ❑RodsiDrop Pipe ❑Check Valve(s) ❑Debris ❑Fill �Jo Obstruction Type of Obstructions(Describe) ___ ______ GEOLOGICAL MATERIAL COLOR HaRONEss oR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. r � �nf Type _ �`� � J Removed �lot Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/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.) s Grouting Material�it�QT(,L�,(/�from�__ to_,_�l�rft. yards�� bags _ from 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? ❑Yes No 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 to the best of my knowledge. Da► staaola well r►rillin�co.�znc. 1692 Licensee Business Na �� License or Registration No. �..---^ ; �j _ �.J ` �...? �fi e r entative Signat�r�„ Certilied Rep.No. Date -- '; yjI�� LOCAL COPY H 3 O��S�r -- _ t -./—`'�/`..c�}`-�y�.. Name of Person Sealing Well or Boring HE-01434-12 IC#140-0423 „ eiosa