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<br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 316 9 ?6
<br /> County Name
<br /> WELL AND BORING SEALING RECORD Mennle9oNa Unique Well No. �
<br /> Minnesota Statutes,Chanter 1031 or W-series No.
<br />�� .r Y Leave blenk�I nol known)
<br /> �����-S.,r�.11.� :x':�G
<br /> Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well o�Boring Constructed
<br />. 't.�.�,-�,� 1l 7 `l'� ('�� F..'!dff ?`'�: N�'� I � �i
<br /> X R.
<br /> ., i
<br /> GPS Latitude_____ degrees minutes_ _ seconds Depth Before Sealing ���r"�� ___._ft. Original Depth _ ft.
<br /> LOCATION: Longitude___ degrees minutes seconds qQUIFER(S) STATIC WATER LEVEL
<br /> Numerical Street Address or Fire Number and City of Well or Boring Location [� �Single Aquifer (]Multiaquifer � .-
<br /> WELLBORWG �Measured ❑Estimated Date Measured '��--j f �"�'-
<br /> �-F��? �'�i�C)[�� �'��� `i r��on �'jNvater-s�ppiy wen ❑Mona.weii �
<br /> Show exact locahon of well or boring Sketch map of well or b ring �Env.Bore Hole ���� ft. j]below ❑above land surface -
<br />° in section grid with"X" location,showing prope y ❑Other_ ._ __
<br /> N lines,roads,and buildin s. CASING TYPE(S) �
<br /> ' � �1 Steel ����. I Plastic �]Tile U Other
<br />� '-- '--- � � /� � ELLHEAD COMPLETION ---- � - ---� � -�------�-
<br /> --`-- ---`�- / �- , W ��
<br /> 'N ' ' ' ' E T `a� � G d I Off
<br /> , 1 r r i Mile � �A1 ra e nside: �Basement set -
<br /> _ ___ __ __ __ __ __ __ � Outside: j �Well House
<br /> � � � � � I A U uned Well Pit
<br />� ; ; ; ; !�Pit ess dapter/ nit n
<br /> B '
<br /> --�--- --�-----�-- ---�-- I � �_�. . � ❑Buried
<br /> L �, ���.Well Pit
<br /> , . S , , � ❑Other ''��
<br /> . �i Mile—� �ll Other_ ��
<br /> PTRO�PERTY OWNER'S NAME/COMPANY NAME CASING(S) `�
<br /> t.�;f)`,"1$$ ��t�.'�. �?�?"T!�q Diameter Depth Set in oversize hole? Annular space initially grouted? ;�
<br /> � Property owner's mailing address if ditterent ihan well location address indicated above __�in.from_ J to i�W ft. [_�Yes �"No ❑Yes Lj No ❑Unknown �
<br /> , �n73 �? 4•layzat�. Flvd, �10
<br /> x,R, _in.from to ft. �a Yes_,, ❑No ❑Yes ❑No �J Unknown
<br /> I:�nU Lake, , 5535f, _ . i�.�
<br /> __.._in.from to__ ft. �__'�.Yes ❑No ❑Yes f�No '�, �Unknown ����
<br /> WELL OWNEA'S NAME/COMPANY NAME SCREEWOPEN HOLE
<br /> Well owner's mailing address it diHe�ent than property owner's address indicated above Screen from /...:�to �`-�� ft. Open Hole from to __ ft �� ,
<br /> OBSTRUCTIONS
<br /> �Rods/Drop Pipe ❑Check Valve(s) [_.�Debris ❑Fill ',�No Obstruction �,
<br /> 5 Type of Obs[ructions(Describe),_ ��� ' *�______,______ �
<br /> �- --_ _
<br />. GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es r;No Describe
<br /> FORMATION
<br /> PUMP
<br /> If not known,indicate estimated formation log from nearby well or boring. � � n C� _ : �.;�.��:��
<br /> . TYPe ._...��___�..r-w�-��.��..�..1�.A>,a.�--�^'�- . .
<br /> ��� ���'� �Removed '�'Not Present ❑Other__._ _
<br />•r::
<br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
<br /> -,...�,�:-.�
<br /> f,�No Annular Space Exists [;Annular Space Grouted with Tremie Pipe �Casing Perforation/Removal
<br /> in.from ___to .__. ft r;Perforated ❑Removed .
<br />� in.from_ to ft. ❑Perforated ❑Removed .
<br /> -- ^R
<br /> Type of Perforalor_ ___,__ __ _
<br /> L;Other__
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> Grouting Material J" from l� to�__.� tt. yards ��"- bags
<br /> i
<br /> from__ to___ ft. ____ yards _ bags
<br /> " ______ from_ to____ ft.____ yards ____ bags "
<br /> OTHER WELLS AND 80RINGS
<br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on properry? ❑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 hue to the best of my knowledge.
<br /> s
<br /> '�;.Inc. IF�a1
<br /> Licensee Business Narpe License or Registration No.
<br /> !�+ /r��F� � •
<br /> . / 1
<br /> ,� �,.�� ,j� . . •
<br /> ; .,°`'`,�' ,s�=�:� = �;�_�- = ___ � -�`-�__�----
<br /> eL�rtilie�R2presentative Signature Certilied Rep.No. Date
<br /> i .__.
<br /> ' LOCAL COPV " � 1 E�2 6 ��y4''�
<br /> —--. ._-- --- ---
<br /> Name of Person Sealing Well o�Boring
<br /> HE-01434-13 IC#140-0423 � snzR
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