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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH M nnesota�J-��and 3onnr� �,.� �O����
Counry Name
WELL AND BORING SEALING RECORD M;��e9ot°un�q�e we��rvo. -----
Minnesota Statutes,Cha ter 1031 or W-series No.
� ILe::�ve blank il n01 hnOwn)
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
� N �2
GPS Latitude degrees minutes___ seconds Depth Before Sealing �Sd � ft. Original Depth ft.
LOCATION: Longitude_ degrees_ . minutes seconds A UIFER(S) STATIC WATER LEVEI
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer t /��`�/
�j, WE�L�BORING �Measured �Estimated Date Measured �7��� !J►'Jr
TT ,�Water-Supply Well i�Monit.Well �/�♦
Show exact location of well or boring .���S ketc map of well or boring Env.Bore Ho�e Other ✓`� ft. below
in section grid with"X." 55-n�"Rocation,showing property. ❑ ___ � ❑above land surface
lines.ro�ds apd bwldin s. -
� N -,.9_� 1 G-[ a (_� _.:�.h..-- CASING TYPE(S)
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�• � � � � ' I�Steel I,]Plastic :_'�;Tile ����Other `
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�� --�--- --�--_==-f- >-' � WELLHEAD COMPLETION �
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: W � � � � E �� .. _
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� __�___ __,__ ' _�__ T t Outside: �. .Well House L�At Grade Inside: ❑Basement Offset `
' � ; � ��AA° � �Pitless Adapter/Unit ❑Buried ❑Well Pit
'-- 5 -% ---�— [
� [�Well Pit ❑Buried
�-1 Mile—� ! � -�Other ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Diam �� � Depth � Set in oversize hole? Annular space initially grouted?
Property owne mail�ng ad ress d diflerent than well location address indicated above �j/ -
�in.from Q to1�ft. ❑Yes [�lo f_I Yes ❑No ��Unknown
in.(rom to ft ❑Yes ]No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes �,I No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAMElCOMPANY NAME SCiiEEN/OPEN HOLE
• �
Well owner's mailing address if diflerent[han property owner's address indicated above SCfeen from_���to���_ft. OpBn Hole from to ft.
OBSTRUCTIONS
.�ods�Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)_ _�1�� /G� P�T�SS _ __._
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? (�Yes [_�No Describe
FOHMATION
If not kno.wn,indicate estimated formation log from nearby well or boring. PUMP
�/--'-� /y r."r TYPe .
"� � ��' � !Remaved �Not Present
❑Other
:��� METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
��lo 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 Per(orator
❑Other
GROUTING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite-50 Ibs.)
� i �
Grouting Material /�k/qT�,�J��.J/ irom� to_fSQ 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 Fules,Chapter 4725.The information contained in this report
is true to the best of my knowledge.
Don Siodola Well Driliing Co,. Inc. 1b91
Licensee Business Name ��� License or Registration No.
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C �ed presenta�ve i ature Certilied ep.No. Date
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LOCAL:COPY H 3 V 5�6 6 --- ` '�w r� `.Ni �-}' �.,.t'v r...r
� � Name of Person Sealing Well or Borin��:
HE-01434-12 IC#140-0423 gi09a