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wELL oR BORING�OCnnON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �!� C O��
County Name
WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. G J
� in Minnesota Statutes,Chapte�1031 or W-series No.
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Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Construded
' 4rcmo Z18 23 35 3-�OQ2,3 �,. ��
GPS Lalitude degrees minutes seconds �/�/''� � �� �
LOCATION: Depth Before Sealing .—�� ft. Original Depth s ft.
Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL
Numericai Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer
ELUBORING �Measured ❑Estimated
� Water Supply Well ❑MonR.Well �
Show exact location of well or boring Sketch map of well or boring
in section gnd with"X" ._��G � location,showing property ❑Env.Bore Hole ❑Other �ft. �below ❑above laixl surface
i� lines,roads,and buildings.
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N �� CASING TYPE(S)
- - - - - -- -i— "'�
Steel ❑Plastic ❑Tile ❑Other
�� W -�- -i— -i-- --i-- E '�,, f�,_,.,,_� WELLHEAD COMPLETION (
� , � � s
: � � � � ' ( Outside: ❑Well House Inside: ❑Basement Offset �
-r- -�-- -r- -i— � � �
�^� ` • �Pitless AdaptedUnit ❑Well Pit
—�- -�-- -�-- -�-- '.'�
I �'
1�'�,��}�ti�. �� ❑Well Pit ❑Buried
S
f'---'�� . �,
❑Buried
PROPERTV OWNER'S NAME/COMPANY NAME CASING(S)
�� �r���� Dia telr Depth � Set in oversize hole? Annular space initially grouted?
Property owner's mailing address rf dilferent Man well location address indicated above /! /'�
� in.frorilS� to,�ft. ❑Yes �No ❑Yes ❑No ❑Unknown
2U00 A�eB Dr
�,.,,�.�t 1��' � � in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unkriown
17lf[.t W\f l l
in.f�om to ft. ❑Yes �No ❑Yes ❑No ❑Unknawn
� WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE "
Well owner's mailing address if different than property ownets address indicated above Screen from t0 ft. Open Hole from�[_t0��
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OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
i Type of Obstructions(Describel ��,,�,rj�� 1/T�C_� !� i�
�e7 �:.- —�-_�
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ NO DeSCfibe �
FORMATION (
If not known,indicate es6mated fortnafion log from nearby well or boring PUMP �E
Type
,F,..,.�.� O�� Y`'�� .
�Removed ❑ Not Pres nt ❑Other
-����` ':.,,.h°�'�-��— � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
i 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.)
�° I
Grouting Materia�f(1�,�, �ff� `���from_�ro��tt. yards �� bags
! from to ft. yards bags
� from to R. yards bags
? OTHER WELLS AND BORINGS -
�
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ 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 to the best of my knowledge.
Scodola Well Dril co. Inc. 27172
Contractor Bu e Name License or Registr.�3tion No.
__ �-- _:✓�.� �/ D�
o d r se' rve �gn�tuA2 Date
LOCAL COPY H Z Z V'J V Z .. �,-,,._. d._i f .,/�3't ,.��1�1.�..
Name ol Person Sealing Well or Bonng
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