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wELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„I �H�
County Name
. WELL AND BORING SEALING RECORD Mennle9oNa Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
�epin ��ee�e e�a�k�,�o,k�ow�> _
Township Name Township No. Range No. Section Na Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed
oren� 117 3 Q 3i 3 /� �UG �� RECEIVED
GPS Latitude degrees minutes seconds ` (�[ O � �
LOCATION: Depth Before Sealing /• � , ft. Original Depth��� / V C�.
Longitude degrees__minutes seconds q UIFER(S) STATIC WATER LEVEL /�
Numerical Street Address or Fire Number and City of Weli or Boring Location ingle Aquifer ❑Multiaquifer ���/// y��QF O
23�8 Rest Pt Crl Vi,V[2V WEL BORING p�Measured ❑ Estimated R�NO
i�
�ater Supp�y Well ❑Monit Well �, �
Show exact location of wetl or boring Sketch map oi well or boring
in section grid with"X" location,showin p�dberty ❑ Env.Bore Hole ❑Other �� tl. �' below ❑above land surface
N (�� lines,roa��uildings. CASING TYPE(S)
3
-- - _ -- _ ,�� �teel Plastic ❑Tile ❑Other
W E WELLHEAD COMPLETION
� �
� � � Outside: ❑Well House Inside: ❑Basement Ottset
' -_-- � ,
---- -�-- --�— ,
' �^'�� �Pitless Adapter/Unit ❑Well Pit
---- -i-- -i-- --�-- �
S � �'S, � ❑Well Pit ❑Buried
�r,nne—�
❑Buried
PROP�R�TsYp OWpNER'Sy�NpAME/CsOMPANY NAME CASING(S)
"�`� r�!^'�1� Di m �r/ Depth � � Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if diflerent than well location address indicated above
� � �� in.from�_ to ft. ❑Yes �No ❑Yes ❑No ❑Unknown
i'l�ht CIL, 51�W2 in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown `�_-
s
in.f�Oril t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOL� �
Well owner's mailing address if diflerent than property owner's address indicated above Screen from � t0�ft. Open Hole from f0 ft.
OBSTRUCTIONS
�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruct�io�1,}
Type of Obstructions(Describe) �l�✓ti'�/�- / ��f ` * ` U��/�
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ NO D2SCfib2
FORMATION
If not known,indicate estimated formation log irom nearby well or boring PUMP �
. _,,� U l�� Type SU E.% �U�T J
~J C�emoved ❑ Not Present ❑ Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
LX No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
!�
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
,� / `'� /
Grouting Material f`���� ��/�,i�.�.{�m � to 1J�ft. yards �bags
from to ft. yards bags
from to ft yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES W SEALING Other unsealed and unused well or boring on property? ❑ Yes �[Vo How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minoesota Rules,Chapter 4725.The information contained in this report is
true to the best of my knowledge. � � - � � _
Dort Str�dola We11 Drilling Co,. Inc. 27172
Contractor Business me . ,.-- _ License or Registration No.
- �
`_�`,;-;.N , = :w.; I..:� -;.:;
A on d epfesentative ignature ' _. Date
H 21 �; , .._ _. �._j,.
LOCAL COPY �r .'r+- _._�'; _/L-,^ i �'�,,}.iY'�,,.
Name of Person Sealing Well or 8oring; �
k... . . � . ._ .. � �. . ... . .