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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I ��](1�Q� WELL AND BORING SEALING RECORD Sealing No. / �.� v C�ty Nam�, Minnesota Unique Well No. r��x�e.�1■[i Minnesota Statutes,Chapter f031 or W-series No. (Leave blenk�rl nol known) Tc..._. ,. "ownship No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Consiructed OtOI]O iZ7 �� } �� E3 r' � �� / ^g � GPS Latitude degrees minutes seconds Depth Before Sealing ! /� ft. Original Depth ft. LOCATION: Longitude degrees minutes__ seconds A �FER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location � ingle Aquifer ❑Multiaquifer �/ ,,... . /� �L/BORING ,�l Measured ❑Estimated Date Measured --•'��f�� 'fr WaterSupply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or boring ��"�' �,/ _ in section grid with"X:' location,showing property �Env.Bore Hole ❑Other __ ft. �below ❑above land surface N lines roads and buildings. CASING TYPE(S) �� --'--- --'-----`-----`- � ❑Steel �iasc�� ❑T�ie ❑Other _ �� --'-----�-----�-- ---`-- � WELLHEAD COMPLETION �` � W ; ; : � ET ,�,t � � � _;__ __r__ Outside: [_I Well House �yrnt Grade Inside: I��Basement Offset �� --�-----�-- - T� �- :. , , , , Mile � � itless A p dUnit ❑Buried f]Well Pit v 1 . 'h til''••� ['P' da te ��- --;--- --,--- ---�-----:- 1 ❑Well Pit L�Buried S ❑Other {--i M�ie-� - � ❑Other _ ' '�-��ti -_.�:_.��-a-�a.. P�PER y/Y WNER'S NAp{��/C ANY NAME CASING(S) j ""•"�� '�"�� Diame �� r Dept/h /_ F Set in oversize hole? Annular space initially grouted? �:, Property owne�'s mailing address it diflerent than well location address indicated above ��n.from� to f r�(C' ft. ❑Yes [�Vo ❑Yes �]No ❑UnknOWn .5 in.from ro ft. [�Yes ❑No ❑Yes ❑No ❑Unknown ___in.from to ft. CJ Yes �]No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � Well owner's mailing address if different than properry owner's address indicated above SCreen ffom �"vc'tL� to ��Q ft. Open Hole irom to ft. � OBSTRUCTIONS �]Rods/Drop Pipe �Check Valve(s) []Oebris �Fill �o Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe - FORMATION If not known,indicate estimated formation log trom nearby well or boring. PUMP Type �' � � � ❑Removed �Jot Present _ ❑Other ; METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: [�o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe �J Casing Perforation/Removal in.from to___ R �]Perforated ❑Removed in.from to .___ft. f]perforated ��]Removed Type of Perforator _ U Other GROUTING MATERIAL(S) (One bag ot cement=94 Ibs.,one bag of bentonite=50 Ibs.) � � f /�t / ,ft ,t�/ Grouting Material��/`�T��/r��/�'Trom�_ to_�._� ft. yards� bags _ from to ft. yards bags ._._ from ro ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? r]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. Uon Stc�dol8 Well Dcilling Co,. Inc. 2691 Licensee Business Name License or Registration No. / �-a� Q i jT'-,�'" �f �> � .� �J�" ,��' / tif(�F I�d Representative Signature. ( Certified Rep.No. Date LqC�.t.COPY H Z�O Z V Z /�"•��.. r.�=t', ..��-�,.�1,,,F-t'�-- %t Name ol Person Sealing Well or Boring 1 : HE-01434-10 IC#140-0423 ' sio�a �