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WELL Op BORING�OCanON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � <br /> CountyWame <br /> WELL AND BORING SEALING RECORD M nnfesoNa Unique Well No. <br /> Minnesota Statutes,Chapter f031 or W-series No. <br /> H�I1T!@ �II �'-°�"�°"""""°"`"�"� <br /> Township Name Township No. Range No. Section No. Frection(sm->Ig) Date Sealed Date Well or Bo�ng Constructed <br /> Oconc� 117 23 R 33-�fl06�i ''� <br /> GPS Latitude degrees minu[es seconds � Q C" � <br /> LOCATION: Depth Before Sealing ft. Original DepthSl..Z—ft. <br /> Longitude degrees minu[es seconds pU1FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aqu'rfer ❑Multiaqu'rfer �,,{' <br /> ,; E ORING lymeasured ❑Estimated <br /> Water Supply Well ❑Monit.Well �� , <br /> Show exact location of well or boring Sketch map of well ory ring <br /> in section grid with"X" location,showi ❑Env.Bore Hole ❑Other �ft. �ielow ❑above land suAace <br /> N lines,roads� uddings. CASING TYPE(S) <br /> � lY Steel ❑Plastic ❑Tile ❑Other <br /> � � � �.� <br /> W -- - -i-- -;-- --;-- E t WELLHEAD COMPLETION <br /> � � <br /> � � �{ Outside: ❑Well House Inside: ❑Basement Offset <br /> --�- ---- -;-- --i— � <br /> � 1��b �❑r'Pitless AdaptedUnit ❑Well Pit �� <br /> —�- -�-- -i-- --�— I a'� <br /> Z ❑Well Pit ❑Buried <br /> ���� � .: ��...�.��-..;. �'� _ ❑Buried <br /> r.__.�,/�. <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) .`� <br /> " ���11 �.�rt8 Diameter Depth � Set in oversize hole? Annular space initialty grouted? <br /> Properry owner's mailing address it difterent than well loca6on address indicated above '�� r/ � <br /> �_ in.ffom� t0�.�ft. ❑Yes �No ❑Yes ❑No ❑Unknown + <br /> in.from to ft. ❑ves ❑No ❑ves ❑No ❑uMcrwwn <br />- in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � <br /> r <br /> Well owner's mailing address if difterent Man properry owners address indicated above Screen from�,.�t0��ft. Open Hole from t0 ft. <br /> OBS UCTIONS ' <br /> �Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) ,��ct/•v�.�' y��� ¢ E"� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM ro Obstructions removed? ❑YBS ❑ NO DeSCfibB <br /> FORMATiON <br /> If not known,indicate estimated fortnation log from nearby well or boring PUMP <br /> dtt�'t 0 85 T'�e -' � <br /> �Removed ❑ Not Prese t ❑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 <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> >, <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> /� i <br /> Grouting Material�(�,L�'��/���T�from�£,�to�ft. yards � bags <br /> from to ft. yards bags <br /> from to R. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING pther unsealed and unused well or boring on property? ❑ Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATIO <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> llari stodoia WeII Drixlin�; Co,. rr�. ;2n72 <br /> Conhactor Business Name License or Registratlon No. <br /> ���// ���f <br /> �presen�t e ' �' Date <br /> H ��1�8� Ji�n Antonson <br /> LOCAL COPY <br /> Name o/Person Sealing Well or Boring <br /> n . <br />