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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 231048
WELL OR BORING LOCATION Sealing NO.
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
I . _ ' Minnesota Statutes,Chapter 1031 or W-series No.
P te."etw�nro awl
- "�% r• Date Well or Boring Constructed
Township Name Township No. Range No. Section No. Fraction(sm-a-Ig) Date Sealed
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GPS Latitude degrees minutes seconds Depth Before Sealing I7. ft. Original Depth ft
LOCATION:
Longitude degrees minutes seconds Apu IFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ,L,�t.�'Single Aquifer ❑Multiaquifer• 2/
WELLBORING L/Measured 0 Estimated
_4-1-)11--)L-' 1 ,1,/ )j I ;i I j ,' �' :j'_;1 t i Y. [/Water Supply Well ❑Monit.Well __
Show exact location of weltor boring ' Sketch map of well or boring r� ft. �elow ❑above land surface
location,showing property 0 Env.Bore Hole 0 Other
in section grid with"N 4
lines,roads,and buildings. CASING TYPE(S)
N
[Steel 0 Plastic ❑Tile 0 Other
WELLHEAD COMPLETION
E .
W I •
--+---+---+-----4, ' Outside: 0 Well House Inside: 0 Basement Offset
t' Jam.
t + t � &" ! VPitless Adapter/Unit ❑Well Pit
( \// ❑Weil Pit ❑Buried
I Mere / 3 ❑Buried
PROPER ...../)
•rr a • • E/COMPANY NAM CASING(S)
Diameter Depth Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above 6•' in.from D to W ft. ❑Yes Lit No ❑Yes 0 No [/Unknown
1 in.from 6 to I D ft. ❑Yes YNo ❑Yes ❑No 'Unknown
in.from to ft. •❑Yes 0 No 0 Yes 0 No 0 Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
Well owner's mailing address if diflerent than property owner's address indicated above
Screen from I-.0 to 1,4- ft. Open Hole from to ft.
OBSTRUCTIONS
❑ Rods/Drop Pipe'--.J .Xleckyalve(s) 0 Debris 0 Fill p'No Obstruction
Type of Obstructions(Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS
TIA ONR FROM TO Obstructions removed? 0 Yes 0 No Describe
FORM
PUMP
If not known,indicate estimated formation log from nearby well or boring VA"
Iii
�V �1,,!fi t1
0 Type / A L
DY1F-1-- �_,;1 v'Removed 0 Not Present 0 Other
"`;rd !H,D 154 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
[/No Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal
in.from to ft. ❑ Perforated 0 Removed
in.from to ft. 0 Perforated 0 Removed
Type of perforator r•
❑ Other
GROUTING MATERIAL(S)(( (Onej, bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
.! ! 1 11'il\i iYl from11
Grouting Material 1<I( 1 � to ��'•� ft. yards `�; bags
from 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? 0 Yes a No 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.
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Contractor Business Name License or Registration
n No.
il1)ir
Date
Authorized Represer$Ative Signature
L, 211 nAR 1 /i,) ! :sn,_l-i -
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MINNESOTA Minnesota Department of Health SEALING NOTICE VERIFICATION
Well Management Section
MDHP.O.Box 64975 This is to verify that this office received a notification on 4/26/2006 that a well
St.Paul,Minnesota 55164-0975 (Minnesota Unique Well No. H000231048) is to be sealed by
DFPARTMFNTOrHFAITH (651)201-4600 or 1-800-383-9808 BOHN WELL DRILLING CO., INC. at:
Well or Boring Location Address: 2655 W LAFAYETTE ROAD EXCELSIOR 55331
Location: Township Name ORONO No. 117 Range 23 W Section 21
This well must be sealed in accordance with the Minnesota Rules on Wells and Borings.
MDH staff may be on site to inspect the well sealing.
RON MARTENS
2655 WEST LAYFAYETTE ROAD
EXCELSIOR, MN 55331
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