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WELL oR BORING LOCaTION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I ��A��� <br /> County Name <br /> WELL AND BORING SEALING RECORD M nn'eso a�Unique Well No. L" <br /> �� Minnesota Statutes,Chapter f031 or W-series No. <br /> ��0a.a ae�k a oo�ww�� <br /> Township Name Township No. Range No. Sec[bn No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> nroc� 217 23 Zl 29 ',. '"� <br /> GPS LaGtude degrees minutes seconds � � <br /> LOCATION: Depth Before Sealing �� ft. Original Depth � ft. <br /> Longitude degrees minutes seconds IFER(S) STATIC WATER LEVEL <br /> Numerical Sheet Address or Fire Number and City of Well or Boring Location Single Aquiter ❑Multiaquifer <br /> WELUBORING Measured ❑Estimated <br /> Water Supply Well ❑Monft.Well � <br /> Show exad location of well or boring Sketch map of well or boring // <br /> in section gnd with"X" location,showin roperty ❑Env.Bore Hole ❑Other �ft. �below ❑above land surface <br /> N �.� liqes,ro a uGd ings. <br /> '---a.,.," +;;�1:.;..�r��' �!J� CASING TYPE(S) <br /> �����, Steel ❑Plastic ❑Tile ❑Other <br /> W —�- - — -;-- --;-- E ....----"""" WELLHEAD COMPLETION <br /> � � � � Outsfde: ❑Well House Inside: ❑Basement Otfset <br /> --i-- ---- -;-- -i— � <br /> �^� �(Pitless AdaptedUnit ❑Well Pit <br /> —�- -�- -�-- --i-- I <br /> 1 ❑Well Pit ❑Buried <br /> S <br /> �—""'�'—�' ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Dia t�r� Depth l Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above f� <br /> � in.ffom" to�ft. ❑Yes �lo ❑Yes ❑No ❑Unknown <br /> if1.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOL�Ej f <br /> Well owner's mailing address it different than property owner's address indicated above Screen from � • t0�/ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> �' Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) ..����./�(� �rP� �' ��/'�6✓ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO ObstructionS removed? YeS ❑ NO DeSCribe <br /> FORMATION <br /> If not known,indicate estimated formeUon log from nearby well or boring PUMP <br /> j �., . Type,� U �J <br /> �f` Removed� ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PeAoration/Removal <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 of bentonRe=50 Ibs.) �^'] `'� <br /> Grouting Material/"�"��� C'�lCJ��from � to�._ft. yards v 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 infortnation contained in this report is <br /> true to the best of my knowledge. <br /> Do�n Stodals T�el I I3rillin� Gt�,. Inc. 27172 <br /> Contractor Business N me License or Registra6on No. <br /> � � '�...% ` l t� �v <br /> A n e 'gnature � Date <br /> LOCAL COPY <br /> H 3 2�5 9 - .,�� ;,,�..����.. <br /> Name ol Person Sealing Well or Boring <br />