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�_ <br /> r _ ► <br /> WELL OR BoaiNG�oCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � � <br /> County Name <br /> WELL AND BORING SEALING RECORD MennlesoNa Unique Well No. <br /> � i� Minnesota Statutes,Chapter 103i or W-series No. _ <br /> (Leeve blenk il na�k��own) <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed - <br /> �rono t17 23 a 44 5 ', ' ;�21�, <br /> GPS Latitude degrees minutes seconds R(w� /y�'� � <br /> LOCATION: Depth Before Sealing `—^'v ft. Original Depth v� ft. <br /> Longitude degrees minutes seconds �FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquiter ❑Multiaquifer <br /> WE L/BORING Measured ❑ Estimated _ <br /> � � �VJater Supply Well ❑Monit.Well � <br /> Show exact location of well or boring � SkePch map of well or boring '� <br /> in section grid with"X" location,showing property ❑ Env.Bore Hole ❑Other ti:� ft �below ❑above land surface <br /> � _`�^�,�lines,roads,and buildings. <br /> N � CASING TYPE(S) <br /> a <br /> � � � <br /> � � --�-- —� '. <br /> teel ❑Plastic ❑Tile ❑Other <br /> W -- - - -- - — -- — E WELLHEAD COMPLETION i, <br /> � � � <br /> r , , , Outside: ❑Well House Inside: �Basement Offset <br /> -�-- -�-- -;— --,— � """"�'� . <br /> � <br /> �^'�� lJ�3Q.�1 ❑ Pitless AdaptedUnit ❑Well Pit <br /> -r- -i-- -�-- —�— I <br /> 1 ❑Well Pit ❑Buried <br /> � S r''`� <br /> r mee� ,��` ;��a.:s"•-�,.����_�e�. . ❑Buried <br /> PRTO.P.ERTYnOt�WtNER'S NAME/COMPANY NAME CASING(S) <br /> fRt� �[il s 952-472�'�7 Diameter Depth^ t Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above ��� y►�� <br /> in.frOfll� to�ft. ❑Yes [�No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � <br /> ��� t <br /> Well owner's mailing address if different Ihan property owner's address indicated above Screen from i, to�ft. Op@n Hole frOm t0 ft. <br /> OBSTFUCTIONS <br /> �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) �.LNI�..��� ��'� 9"' ��� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 2S ❑ No DeSC�ib2 <br /> FORMATION <br /> It not known,indicate estimated formation log from nearby well or boring PUMP . <br /> r^� J�_T �v�p <br /> J� ;�.J � TyPe <br /> t'�� �Removed ❑ Not Present ❑Other <br /> � METHOD USED TO 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 /> / � <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> ' GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag o�bentonite=50 Ibs.) <br /> Grouting Material �"/��r `�-����'�'�?rom � to � ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS � <br /> c' <br /> REMARKS,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 coniained in this report is <br /> Irue to the bes[ot my knowledge. <br /> Don Sti�d�a �tell Dcillir� Co,. Inc. 27172 <br /> Contractor Bus�ess arrrc License or Registration No. <br /> �."' � �� /�,� �7 q <br /> tho�ed epresentative tur � Date <br /> �4\ .' <br /> 218145 ` ' �"`` <br /> LOCALCOPY H �� <br /> Name ol Person Sealing Well or� <br />