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,' WELL OR BORING�OCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I
County Name
WELL AND BORING SEALING RECORD Minn'esota Unique Well No.
Minnesota Statutes,Chapter f031 or W-series No.
t�eeVe ae�t n�a�own�
Township a Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed
OLO[l0 �.1� ��. �� ��. (J�j Q
GPS Latitude degrees minutes seconds C,� �
LOCATION: Depth Before Sealing � y3� ft. Original Depth (t.
Longi[ude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL
+ Numerical Street Address or Fire Number and City of Well or Boring Location Single Aqu'rfer ❑Multiaquifer
WELUBOR�NG �Measured ❑Estimated
�Vater Suppty Well ❑Monit.Well �
S ow ct I� ` o rin � Ske ell or n
in section grid with"X" location,showing pro ❑Env.Bore Hole ❑Other �D ft. elow ❑above land surface
lines,roads,and buildi g .
N - -- CASING TYPE(S)
_ _ _Y_ _ __ _ __ �
{l
T , P' Steel ❑Plastic ❑Tile ❑Olher
w --F- - -- - -- --;-- E � � WELLHEAD COMPIETiON
� ' � ! y
� � Outside: ❑Well House Inside: ❑Basement Offset
-;r- ---- -+- -i— 7{y
1�� J �'��` �Pitless AdaptedUnit ❑Well Pit
--�- -�-- -i-- --i-- I � '�
1 ❑Well Pit ❑Buried
S
�—""'�—�' ❑Buried
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Diame er� / � Depth J Set in oversize hole? Annular space initially grouted7
Prope owner s mai ing a ress i itteren ihan wel oca ion a ress dicated above ,�,`'
� in.ffom� to_��. ❑Yes �vo ❑Yes ❑No ❑Unknown
7\
in.ffOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
� in.ffOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
i � t
Well owner's mailing address if diNerent than properry owneYs address indicated above Screen from t0 ft. Open Hole from�20�ft.
OBSTRUCTIONS
`dRods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
J� /�
Type of Obstructions(Describe) ��/V��.,,�� � �U�/�
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM 70 Obstructions removed? es ❑ No Describe
FORMATION
If no[ own,indicate estlmated formation log irom neaiby well or boring PUMP
7Ype ��..�� �(1f��
Removed ❑ Not Present ❑Other
f � � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
y�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
a ❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material���/ �'��,eCI �Arom�—to.�.].S.iI.' yards � bags
` from to ft. yards bags ;
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SJURCE OF DATA,DIFFICULTIES IN SEALING pther unsealed and unused well or boring on property? ❑ Yes o How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The infortnation contained in this report is
true to the best of my knowledge.
I3o� Sta�ola �?elI Drillin� Co., Tnc. Ih�31
Contractor Business Name License or Registration No.
''�J ^. '�.�✓i i,...'�
A n d S' Date
LOCAL COPY H S 1 ( �iJ '. . _ �;,:..,..:r..ir;�,-�..r.,.
Name ol Person Sealing Well or Boring