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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �} �`7 'i WELL OR BORING LOCATION Sealing No. H ar� -� ..)�� ,.. ' County Name � WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Cha ter 7031 or W-series No. . �t'ililE� lO � p «aa�a ti��k��o,k�ow�, � Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed ' L�ciano II7 23 06 N� l� S'�° / GPS LOCATION- decimal degrees(ro four decimal places) `J � Depth Before Sealing '7� ft. Original Depth ft. Latitude________._____ Longitude .____ A�UIFER(S) - STATIC WATER LEVEL Numerical Street Address or Fire Number and City ot Well or Boring Location �Single Aquifer '�_J Multiaquifer ,�!�� /��►✓ 559 Park Lane e�'�� 5535� W uBORING �jMeasured _IEstimated DateMeasured_�I'!►�__rr_t)n7 � Water-Suppiy Well i_l Monit.Well � Show exact location of well or boring Sketch map of well or b ring � ��Env.Bore Hole � i Other__.__ 2� ft. '�below - �,above land surface in section grid with"X:' Ioc�tlon,showing prope y �� - - - - -- � � N lines,roads,and bwldin s.�� CASING TYPE(S) �.:' '--- -`- `-- `{ ,��,/ Q (� I � � j j j �;'�.' �Steel I�,Plastic � '.Tile �. ,Other _ . _ _ ,`��+�I��D � -- --- ------ ----- --- -- �� .. WELLHEAD COMPLETION �-� , � � . W ; ; ; ; E � SEP - 2015 � � � � T s �� Outside: ��i Well House ! 'At Grade Inside: � �� ___ _ __ I ]Basement Offset + 'h M�ie � � n �Buried ']Well Pit � � � .__Pitless Adapter/Unit ;:��'^ �� L]Well Pit !�Buried - �'I� OF ORON 5 � ��Other �—i M'�ie—� �`Other PROPERTY OWNTE�,R.'S NAME/CyOMPANY NAME CASING(S) J�� +�V111�Q�1 Diameter � Depth � Set in oversize hole? Annular space initially grouted? Property owners mailing address if differen�ihan well location address indicated above �� / " -- - i-� 2 in.from c�_ to_��_____ft � �Yes �No !_I Yes �_No �1 Unknown �.0. kix 532 , �� in.from __ to __,__ft �j Yes �_J No '��Yes �?No ❑Unknown . In.from to. ft. ;',Yes `�No �]Yes �J No �j Unknown � WELL OWNER'S NAME!COMPANY NAME SCREEWOPEN HOLE Well owners mailing address it different than property owner's address indicated above SCreen from_. �J r_to ��' fL Open Hole from_____ _ to _ft. OBSTRUCTIONS _j Rods/Drop Pipe ,_'Check Valve(s) �_ �.Debris i �,Fill �No Obstructlon Type of Obsiructions(Describe) ' GEOLOGICAL MATERIAL COLOR HARONESSOR FROM TO Obstructions removed? L.'�Yes i_I No Describe FORMATION PUMP If not known.indicate estimated formation log from nearby well or boring. r TYPe -— _-. .__------ ' � � �'"� �,Removed ��Not Present !]Other_ _. __ __ _ _ _____ _ ___ � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: .No Annular Space Exists [ I Annular Space Grouted with Tremie Pipe �,.i Casing Perforation/Removal �� __._______,_,__in.from__ _ to ft. ` ;Perforated �_ �Removed �� > _ _ _in.from,___ __ _.__ _to_____ ft. i 1 Perforated `]Removed �> Type of Perforator VARIANCE Was a variance graMed from the MDH for this well? i_�.Yes i No TN#__ __ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) � Grouting Material��L from�r__ to_�� ft. yards..�___ bags �,- -_._-__.___.._._._--- from__, to ft. yards. --- bags ;. from___._._. to_______ ft._ yards_ _ bags �i� OTHER WELLS AND BORINGS = REMARKS,SOURCE OF DATA,DIFFICULTIES W SEALING Other unsealed and unused well or boring on property? � i Yes � o How many? �� LICENSED OR REGISTERED CONTRACTOR CERTIFICATION � This well or boring was sealed in accordance with Minnesota Rules.Chapter 4725.The information contained in this report is true to the best of my knowledge. Ikrn St«lols [�ell. Acillin�; Co,, Inc. 1691 Licensee Business me � License or Registration No. � � �: _ ,�� . �,�- l� r� , l /, n' � : .—..-- ..... __.. .—". . — — —.—_ _". —._—_—._. '_ _— r ed� resenfafive Signature ' �� Certified Rep.No. Date t, � �'�, ./,�.Rs'�c� : LOCAL COPY " 3 3 3�7 3 -__-- ----- - ---= -_ �'= Name of Person Sealing Well or Boring -- - ------------ HE-01434-14 IC#140-0423 � � 5�t3R