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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„' °� �� A � County Name WfLL AND BORING SEALING RECORD Mennle9oNa Unique Well No. ,) �} �♦ ) Minnesota Statutes,Cha/�ter 1031 or W-series No. }�y.Q11f'1��i)l f1 r (Leava blank�if not known) �Ail �L�1 Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed Orano 117 23 lFi AI6 I�E4 r'�i / f� GPS LOCATION- decimal degrees(to four decimal places) Q � Depth Before Sealing CJ� ft. Original Depth ft. Latitude Longitude A UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer /� �7� �a�Q,,�}'g �yQ�2'jr �� i•Onfl WELL/BORING �vleasured ❑Estimated Date Measured',--��'��i� �1/4,� - Water-Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or boring in section grid with"X:' n+ location,showing property ❑Env.Bore Hole ❑Other �?�fl. below ❑above land surface N � lines,roads,and buildings. CASING TYPE(S) --'-----i-- --`-- ---'-- Steel ❑Plastic ❑Tile ❑Other --�--- --�--- ---�-- ---�-- ' + ELLHEAD COMPLETION W E� � W � � � � � / f~� Outside: ❑Well House ❑At Grade Inside: �Basement Offset -- ------- ----- ---- .�__ , , , � Mile � dless A p r/Unrt ❑Buried ❑Well Pit , , , , 'h �� j �]P' da te ' ------------ ------ ------ 1 ._ ❑Well Pit ❑Buried S ❑Other �7 Mile—� �f Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) ?�i rt �ve1a � nt �et�vi�ce�, L� Diam ter � Depth r Set in oversize hole? Annular space initially grouted? Properry owner's mailing address if diflerent than well location address indicated above �� �in.from�� to��ft. ❑Yes �No ❑Yes ❑No ❑Unknown ��47 �lln�et Trl ' �r��nfiel!�, �� 55357 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown - RECEIVE in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE� SEP C� 6 201 r Well owner's mailing address it different than property owner's address indicated above Screen from �� to ��ft. Open Hole from to ft. �ITY OF ORON OBSTRUCTIONS Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction ..... Type o(Obstructions(Describe)�r11lUe�/C_ �� }' �V/�, GEOLOGICAL MATERIAL COLOR HARDNESS oR FROM TO Obstructions removed? Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. C�� J��n � .,'� 7ype_...1 f' �_r Removed ❑Not Present ❑Other / r 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 VARIANCE . Was a variance granted from the MDH for[his well? ❑Yes '�No TN# GROUTING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite=50 Ibs.) N� /�" T _�__ �L_ _� Grouting Material Lt�O�f,(J from 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? U Yes 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 ta the best of my knowledge. ?ksn �ta3ola Well Dciltin�; Ca, Inc 1�i91 Licensee Busipess Name � License or Regisfration No. ��• � �,. ,.._ .�'.r`f!. - , --' '�. I -:�• �.:.r �rti ed RepresentativE Signature Certilied Rep.No. Date H -� �16 4 3 , ,�-.y..-._ � -�,v��-�-�. LOCAL COPY •..� Name ol Person Sealing Well or Boring, HE-01434-14 ID#53159 �' si�3a