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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 4 6 91. 7 <br /> County Name <br /> WELL AND BORING SEALING RECORD M nnle90 a�Unique Well No. <br /> Minnesota Statutes, Chapter 1031 °Ba�N-s eries No. <br /> Tow Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed <br /> ,, ,, ,, f j <br /> GP L � ION- decimai egrees(to four decimal p�laces) '� �r L ` <br /> ` // <br /> Depth Before Seating f �/ fl. Original Depth ft. <br /> Latitude___ Longitude__ _ <br /> AqUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Multiaquifer <br /> t}1F�,5 '+��,r� ,��[,Q �r� �r��,?O ���1!; WELUBORING Measured ❑Estimated Date Measured S�m� ��� <br /> ' � Water-Supply Well ❑Monit.Well � <br /> Show exact location of well or bOring Sketch map of weil or boring / � <br /> ' in section grid with"X" Iycaj�on,showing property U Env.Bore Hole ❑Other _ _�-= ft. �below ❑above land surface <br /> � 7�ne�,roads,and buildings_.... <br /> N . -�^^-�� � . CASING TYPE(S) <br /> _"'1""-^-------_:,.__�.�!: ` .. �t <br /> : � � � � . --.�_...,�„�� <br /> --'------'--- --`-- --'-- ' <br /> ���'� --'-----;--- ---`-- ---`-- � ELLHEAD IMPIETI N�le th _--- — — ,-_.__— — <br /> ❑P uT ❑O er <br /> W ' ; ; ; E . I W °° ° �ECENED <br /> ______ _______ _ T Outside: ❑Well House �_)At Grade Inside: ❑Basement Offset <br /> � <br /> "�-" I I I <br /> � ; ; ; ; 'h M'ie itless A p r/Unrt ❑Buried �Well Pit <br /> � �� <br /> . <br /> , , , , � � ❑P' da te 1 3 ZO�� <br /> --�--- --T-- ---�-----�- <br /> � ❑Well Pit ❑Buried JUN <br /> ��Miie--{ ❑Other ❑Other <br /> � F; " pF ORONO <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) �- <br /> �+(?[f�.'�n T_;jjl(j`!'��'j Diameter ) Depth / Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above ��� <br /> �_in.from � to��ft. ❑Yes [�Jo ❑Yes [�No n Unknown <br /> in.from to ft ❑Yes ❑No ❑Yes '�,]No ❑Unknown <br /> in.from to R. ❑Yes []No ❑Yes ;]No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> I / <br /> Well owner's mailing address if different than properry owner's address indicated above Screen from���to .��:��1� fl. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS Ofl FROM TO Obstructions removed? ❑Yes U No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> ' �/ Type <br /> F,.J <br /> ❑Removed �Not Present ❑Other <br /> = METHOD USEDTO SEAL ANNUTAR 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 PeAorator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? �Yes No TN# <br /> GROUTING MATERIAL(S) (One bag ot cement=94 Ibs.,one bag of bentonite-50 Ibs.) <br /> w� r / <br /> Grouting Materiallv�-�%^���C1f from_�� to� ft. yards� bags <br /> from to ft. 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 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 contained in this report <br /> is true to the best of my knowledge. <br /> T1nn �;tn��}�,a [dP�� �C����[}�-GE?s-. �4'1E. ���� <br /> Licensee Busmess Name �ense or Reg�strahon No. <br /> ' //� f� <br /> �� Y:. <br /> ; �. — /_:..� - f `�] <br /> = s <br /> Certifjeo'Representative Signature �� Certified Rep.No.� Da[e <br /> , � (,.,._,� _„�.—e�-, .I•. {'�� <br /> " 3��917 �„t,,..r � _3� _:..� <br /> LOCAL COPY Name of Person Sealing Well or Boring � <br /> HE-01434-14 ID#53159 ' Sn3a <br />