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� , ._ _ _ _ ,: _ _ <br /> , � <br /> WELL OR BORING LOCATtON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' <br /> Counry Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. <br />- ��� i� Minnesota Statutes,Chapter 1031 or W-series No. <br /> (�eeve denk n na wwww�,) <br /> Township Name Township No. Range No. Sectio�No. Fraction(sm-i Ig) Date Sealed Date Weli or Boring Canstructed <br /> t?rt)[!O 117 23 �7 �% �,. �,. ��. " L <br /> GPS ��de degrees minutes seconds � <br /> LOCATION: Depth Betore Sealing ��� ft. Original Depth ft. <br /> Longitude degrees minutes seconds ppUIPER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> � C � WELUBORING Measured ❑Estimated <br /> � � `GYWater Supply Well ❑Monit.Well <br /> Show exact location of well or boring map of well or boring l� �';°'"r�> ° `/ <br /> in section grid with"X" on,showing property ❑Env.Bore Hole ❑Other _`- �• ry. f7�elow ❑above land suAace <br /> lin `o�s,•and buildings. r� <br /> N �A CASING TYPE(S) <br /> =� <br /> I I � � <br /> ���'� �l; ❑Steei lastic ❑Tile ❑Other <br /> ' � , , � • �"� <br /> W --�- -�-- -;-- --�— E /�� / ��� WELLHEADCOMPLE110N , <br /> � , � � _____. � <br /> � � � � � �/ /� �Outside• ❑Well House Inside: ❑Basement Oifset <br /> --�- -:- -;-- --a-- / \ -.__.�.❑ a ❑ <br /> `� ' ' ' ' �� � PiUess Ada tedUnit Well Pit ��. <br /> --�- -�-- -�-- --�— I j� <br /> � � � � �- ❑Well Pit ❑Buned <br /> S <br /> �'—�'"'�°—�" ❑Buried <br /> J�xT io r <br /> ��� PROPERTY OWNER'S NAMEJCOMPANY NA�ME�q� CASING(S) <br /> �C��� ����� �+�d Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above /f / t <br /> � m.f�om1�_ t0�ft. ❑Yes �o ❑Yes ❑No ❑Unknown <br /> 4420 Shoecline 1)t c.� �� <br /> S�� �L„1�' � t�T�3� in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> R J <br /> � .�.' � ir1.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> �� WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> � f <br /> Well owner's mailing address if diNerent than property owners address indicated above Screen from��t0�Q_ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS r <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �o Obstruction <br /> Type of Obstructions(Describe) <br /> r <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑YBS ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated fortnation log from nearby well or boring PUMP <br /> Type <br /> ❑ Removed ot Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> (�Jo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perloration/Removal <br /> in.from to ft. ❑ Perforated � Removed <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 Ibs.) <br /> j / / � <br /> Grouting Material�R(�,�� ��/��d/��from_�L to L�ft. yards �_ bags <br /> from to R. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <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 infortnation contained in this report is <br /> true to the best of my knowledge. <br /> non �tvdola �1e11 Dri2iin� Ca,. Inc. � %>/ <br /> Contractor Business ame License or Registration No. <br /> � -- iT�� <br /> „;?':� -�" p':. 9. � <br /> A d epresentatrv Signature Date ' <br /> LOCALCOPY <br /> H 4g�as �� �r� <br /> Name of Person Sealing Well or Boring <br />� <br />