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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 316 9 2 2
<br /> County Name
<br /> WELL AND BORING SEALING RECORD Menneso a�Unique Well No.
<br /> Minnesota Statutes,Cha ter 1037 or W-series No.
<br /> �Ay�eA�'��f P (Leave dank it not known)
<br /> G3112 ��
<br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
<br /> i�rono 117 23 2� t�TF' N� S�� ?C.> C:;�.; �'�
<br /> GPS Latitude . degrees___ minutes__.., seconds Depth Before Sealing� � __ft. Original Depth ft. �
<br /> LOCATION: Longitude degrees minutes seconds
<br /> �IFER(S) STATIC WATER LEVEL -
<br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �^ rt
<br /> 2975 C.asco �01nt RU, ��QL� �UBORING �Measured ❑Estimated Date Measured _J J��'/�� ��
<br /> `� Water-Supply Well ',�J Monit.Well r� �,
<br /> � Show exact location of well or boring Sketch map of well or boring �Env.Bore Hole ' ',Other_ _
<br /> : in section grid with"X:' location,showing property — _— ._— 4'� —h �,below [_]above land surface -
<br /> N lines,ro�s,and 4uilding�. CASWGTYPE(S)
<br /> ,�� IC
<br /> --'— - - �- •- � '
<br /> "� , ( �Steel [ I Plastic [_�Tile �._!Other _ ���
<br /> � � --- ._----�--
<br /> '� '"'"" "'"' '`' '- WELLHEAD COMPLETION
<br /> 1
<br /> •� W , . , , E � .
<br /> : __;___ __I__ __�____r T y�`° Outside: r,Well House �]At Grade Inside: �Basement Offset
<br /> 'h Mile A :T
<br /> �� --;-----T-----f-----:-- itless A p r/Unit �-� uned � ell P�it
<br /> 1 [�P� da te � B ��W �:
<br /> ❑Well Pit ❑Burie ��
<br /> S ❑Other
<br /> �--i Mile� ❑Other ^
<br /> +
<br /> z
<br /> PROPERTY OWNER'S NATM�E+/COMPANY NAME CASING(S)
<br /> �tonec,aoo�i IiLw� Diamete� � Dept�'l � Set in oversize hole? Annular space initially grouted?
<br /> Property owner's mailing address if ditterent than well location address indicated above _ � _in.from � to ��/ ft. �J Yes �i No �_.�Yes [�.No ❑Unknown
<br /> 7�f�7 �+�8,Z$ta gl�T� in from to ft. [j Yes Li No �Yes ❑No ❑Unknown
<br /> St Lc�uis pack, t��1 55426 - - .
<br /> in.from___ to ft. L:I Yes ❑No ❑Yes ❑No ��.1 Unknown
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
<br /> a . i
<br /> Well owner's mailing address if different ihan properry owners address indicated above SCreen frOm / � to��__ft. Open Hole from to ft.
<br /> f�OB TRUCTIONS
<br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �]No Obstruction
<br /> Type of Obstructions(Describe) ��/UrK �1!�� 4 �/IG J'
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe
<br /> FORMATION
<br /> PUMP
<br /> If not known,indicate estimated formation log from nearby well or boring. '('� 1�.
<br /> Type__J= t �U n1�
<br /> � �d�-�— �� ��� �Removed �I Not Present I_�Other
<br /> j METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
<br /> ��o Annular Space Exists '�,'��Annular Space Grouted with Tremie Pipe i�Casing Perforation/Removal
<br /> ___ in.from_ to _ft. [_i Perforated ❑Removed
<br /> in.from __to ft. �__�Pertorated ��Removed
<br /> i
<br /> Type of Perforator _______
<br /> r�Other_
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> r
<br /> ,n / n
<br /> GroutingMaterial/�/G,/'�%t,��`��t����rom CO to��" � ft.______ yards__� bags
<br /> from to ft. _ yards bags
<br /> _ _ from ro __ 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 information contained in this report
<br /> is true to the best of my knowledge.
<br /> 1.km Star�ola We11 Driliin�; Co,. Ir�c. 1691
<br /> Licensee Business lyame License or Registration No.
<br /> < f
<br /> i f �—�y��,�.!�
<br /> , . �E��s�r?:___�-. .�,:. �
<br /> � � ,- �.��-� �.�1- /,�
<br /> 'Certilied Aepresentative Signature Certified Rep.No. Date
<br /> 316 9 2 2 � '�'�"��``"
<br /> IOCAL COPY H .��•"`" _
<br /> Name of Person Sealing Well or Boring
<br /> HE-01434-13 IC#140-0423 � sii2R
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