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WELL oR BORING LOCA7iON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' ��c�
County Name
WELL AND BORING SEALING RECORD MennesoNa Unique Well No. J
�� i� Minnesofa Statutes,Chapter f031 or W-series No.
��ea.e eie�x n�m w�own�
Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed
4rono 117 23 0 32 24 ',. ',. (' p�'
� ,
GPS Latitude degrees minutes seconds Qj� Q/�
LOCATION: Depth Before Sealing L"" ft. Original Depth s-�`-' ft.
Longitude degrees minutes seconds pQU1FER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and Ciry ot Well or Boring Location Single Aquifer ❑Multlaqu'rfer
WELUBORING �Measured ❑Estimated
�Water Suppty Well ❑MonR.Well
Show exact location of well or boring Sketch map ot well or boring
. in section grid with"X" location,showing property ❑Env.Bore Hole ❑Otlier �tt. �below ❑above land surface
lines,roadS and buildings.
N ���' CASING TYPE(S) ,
- - - - - -- - -- �•._,,:_.,F�j t�.,i�r.�'�`.i Jt",��.,.
..�.rrw� ��" Steel �Plastic ❑Tile ❑O[her
W -- - -i-- -i-- --i-- E ��. � .�.. �. .r. .. , WELLHEAOCOMPLEl70N
-'r- ---- -;-- --i-- � ^ �.{�O�i�/,f3r� � ��81�' ❑WeIlHouse Inside: ❑BasementOffset
�� _ , � � ❑Pitless AdapterlUnit ❑Well Pit
—�- -�— -i-- --�-- � . � . . .�
a
�+-���� ❑Well PR ❑Buried
�—�'"'�'—�' �Q'Buried
I�
� PRaO,P,,ERTY,tOWNER'S NAM�E�/.C.�O,M.PANY NAME CASING(S)
�:�V�11 a� .7VEfD Diameter Depth Set in oversize hole? Annular space initialty grouled?
Property owner's mailing address if different than well location address indicated above /t
�_ in.ffom� to � ft. ❑Yes �No ❑Yes ❑No ❑Unknown
11G01 Cty Rd 3
a�AipR.117$� MN 55343 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
�; WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
I��_ + t
Well owner's mailing address if diHerent ihan property owners address indicated above Screen from�5,�t0�ft. Open Hole from 10 1I.
OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe)_��c1�t������'��;f s i
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ NO DBSCflbO
FORMATION
If not known,indicate estimated formation log from nearby well or bonng PUMP
�C�f� � � Type
❑ Removed Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PerforatioNRemoval
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 Materiay�,{��%�.�(1"��� from�_to�2�ft. yards � bags
trom to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
�� REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other 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 information contained in this report is
true to the best of my knowledge.
llonseodola i�ll Drillin,� ca., rnc. z7172
Contractor Busi ss ame � 7 License or Regist�ation No.
,^" i
.
/-��� �..J v.--�.�� � —
o presen abve Sign e Date
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LOCAL COPY
H 3 5'�2 5 : _ �,_ .,._,: ,1-,.__
Name o/Person Sealing Well or Bonng -