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wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„'
Counry Name
WELL AND BORING SEALING RECORD MennlesoNa Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
�Ledve blank i�nol know�)
Township Name Township No. Range No. Section No. Fraciion(sm-->Ig) Date Sealed Date Well or Boring Constructed O
(hono 11�3 23 36 1-�i5 . 2.U f}t� a� � ��1�
GPS Latitude degrees minutes seconds / /�, / y�.*��,/�� � n-y- �
Depth Before Sealing / �`�' ft. Original Depth /���t�7 tt. v�1 Y s
LOCATION: V�: -
Longitude degrees minutes seconds pQU1FER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Weil or Boring Location ingle Aquifer ❑Multiaquifer �/ O
WELUBORING QrMeasured ❑ Estimated
� [�Water Supply Well ❑Monit.Well �
Show exact locatio of well or boring Sketch map of well or � / ,��
in section grid with"X" location,showing pro rty�j ❑Env.Bore Hole ❑Other �—J ft �below ❑above land surface
N ,\ lines,roads,and buildi S�z CASING TYPE(S) �
21(
i i � i �W � v
�_ _i__ __i__ __
'� TfE'Steel ❑Plastic ❑Tile ❑Other
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W -- - - -- - -- -- — E 0 �� WELLHEAD COMPLETION
� � � � � � � Outside: ❑Well House Inside: ❑Basement Offset
-�- -�-- -;— --�-- �
Y�mi�e _,_ l �itless AdaptedUnit ❑Well Pit �`
—�- -i-- -�-- --�— � � :ti .
Y ❑Well Pit ❑Buried
S
�r mAe� -'
❑Buried
PROPERTY OWNER'S NAME/COMPANV NAME CASING(S)
T � 952-47fr2581 Diameter/� Depth � Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if ditterent than well location address indicated above � ���/
� in.ffom�__ to��,ft. ❑Yes �yNo ❑Yes ❑No ❑Unknown
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in.frOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
In.f�Ofn t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
♦ �
Well owner's mailing address if different ihan property owner's address indicated above Screen from � t0��ft. Open Hole from t0 ft.
OBSTRUCTIONS �
�iods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstjruction
Type of Obstructions(Describe)�L(/1�/� �rI'� �'" / V���
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Y2S ❑ NO D2Sc�ib2
FORMATION
If no�known,indica�e estimated formation log irom nearby well or boring PUMP
` J�i TYpe ��.i��. �/)�'� ("?
�� � r�yrvr
[�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 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.)
n; < yy�,t-�" a �'� � �
Grouting Material ���/Y ��i` om t 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? ❑ Yes o How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The informalion contained in this report is
true to the best of my knowledge.
Don Stvdiiia �ell Drilling Co, Ir�c. 27I72
Contractor Business me _ � License or Registration No.
, ,� 1 - ��3
o d es'ntative gnature.- Date
�..-r�-- •_..�.�"� ,A..J�V�-:CUI�C�-' .
LOCAL COPY H 213 7 71 Name ol Person Sealing Well or��