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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Weli and Boring H � ��4 5 3 <br /> County Name <br /> WELLAND BORING SEALING RECORD Mnnesoa�UniqueWellNo.� <br /> e! Minnesota Statutes,Chapter]037 o�W-series No. p <br /> �c':! .$�. 0.eave war�n nm knovn,� �Qsa�.� — — <br /> ot <br /> 6m <br /> Township Name Township No. Range No. Section No. Fraction(sm.-•Ig.) Date Sealed Date Well or Boring Constructed <br /> �Can� 2I� 2� Cll S� SE S� �."�.,. 4 ""� �;j,�'`'� !1 .,�;�r <br /> GPS LOCATION- decimal degrees(to four decimal places) ['� � . ." '` <br /> Depth Betore Seating �l�� ft. Original Depth g. <br /> Latitude Longitude ,, � <br /> IFER(S) STATIC WATER L L '�+'✓= , � � � <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location Single Aquifer ❑Multiaquifer ' ' � rvf An <br /> �� ����� �� '��nr A^►..,.r,., WELUBORING �teasured ❑Estimated Date Measured S�_ s _�,t�r ��Y� <br /> 4�suRiV Water-Su I Weil <br /> pp y ❑Monit.Well c`,�� <br /> Show exact location of well or boring Sketch map of well or boring Env.Bore Hole <br /> in section grid with"X:' loc tion,sh�, gpraperty ❑�her +"� ft. �below ❑above land surface <br /> N ,roads,ar)p3bwi ng�. CASINGTYPE(S) <br /> ..!✓f ..sc.. <br /> --�----i----�-----�-- � <br /> �Steel ❑Plastic ❑Tile ❑Other <br /> --=-----=-----`-----�-- � WELLHEAD COMPLETION <br /> W : : ; ; ET ' � <br /> _ �_____�____�_____�__ Outside: ❑Well House ❑At Grade Ineide: ❑Basement Offset <br /> 'h Miie ❑Pitless Adapter/Unit �uried ❑Well Pit <br /> --:-----r-- ---------=-- 1 <br /> ❑Weil Pit ❑Buried <br /> , � S � � _ _� ❑ <br /> __....., <br /> ,A,.___ � -- ther <br /> �t Miie�.. -� � � Y''� ❑Other <br /> � a �> ,(;:_s►..,, <br /> P�R+OPERTY OW�+N�ER'�S NAME/COMPANY NAME CASING(S) <br /> 1+� �.�G�� Diameter � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property ow�er's mailing address if diHerent Ihan well location address indicated above I��, � <br /> �in.irom�_ to�_ft. ❑Yes No ❑Yes ❑No ❑Unknown <br /> r���,.�����+� ���T� g in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 1'.V�21UZ A7R��,j C�:� ���.7� <br /> in.from ro ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> t f <br /> Well owner's mailing address if different ihan property owner's address indicated above SCreen ffom�_to��ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> �ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions{Describe)�it)`r�J�� f'"„{f"Y � 1./�r <br /> GEOLOGICAL MATERIAL COLOR HARONESS OR FROM TO Obstructions removed? [�es ❑No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> �iL �,+ [�t TYPe <br /> ❑Removed �lot Present ❑Other <br /> M�OD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to R. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE . . <br /> Was a variance granted from the MDH for this weli? �Yes o TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonke=SO lbs.) <br /> � �g r +� <br /> Grouting Material���i��� from � to T�� ft. yards '�*�" bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORWGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes o 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 ro the best of my knowledge. <br /> I1o�t Stt�fll� tdeil�ri3lit� �,. �I.t�. llag�. <br /> Licensee Business Na�ne ,, � r- License or Registration No. <br /> ,.� .`'` � j'' <br /> P ( ." <br /> _-Xf'' �'_ �`''� r"-���y.!'�... .. � <br /> � ',�T /,���1``� '�."''' -+F'�f Y'" �'�`���� <br /> C, �iezl R�irt2�$�gnature Certilied Rep.No. Date <br /> " 329453 J�' �''°� <br /> LOCAL COPY Name o/Person Sealing Well or Boring <br /> HE-01434-14 IC#140-0423 5/13R <br />