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wELL OR BOR�NG LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I �F�� ��
Counry Name
WELL AND BORING SEALING RECORD M nnlesoNa Unique Well No. L
� i� Minnesota Statutes,Chapter 1031 or W-series No.
0.��aeok n�m k�own�
Township Name Township No. Ranc�e No. Section No. Fraction(sm-�Ig) Date Sealed Date Well or Boring Constructed
C#rar� 17 23 f)6 �,. �,. �,.
GPS Latitude degrees minu[es seconds ,�
LOCATION: Depth Before Sealing ft. Original Depth tt.
Longitude degrees minutes seconds p UIFER(S) - STATIC WATER LEVEL
Numerical Street Address or Fire Number and Cily of Well or Boring Location Single Aquifer ❑Multiaquifer
W LLBORING �Measured ❑Estimated
7� A � � Water Supply Well ❑Monit.Well (
Show exact location of well or boring Sketch map of well or boring
in section grid with"X" bcation,showing property ❑Env.Bore Hole ❑Other ��ft. below ❑above land surface
N ,and buildings. CASING TYPE(S)
- - - - - -- - -- '+ �
� Steel ❑Plastic ❑Tile ❑Other
W --�- - — - -- --i-- E � WELLHEAD COMPLETION
� � � Outside: ❑Well House Inside:�Basement Offset
-;-- ---- -r- -i--
!�� ❑Pitless Adapter/Unit ❑Well Pit
—�- -�-- -�-- --i-- I
1 ❑Well Pit ❑Buried
�—""i1°—�' �{f , ❑Buried
/:J '�..�J;.%ft�a _ .
��� PRLO�PERTYt OWtN�.E,,Rw'S�NAME1/�COMPANY NAME CASING(S)
i'�1�i ln.�ll� 1� Diameter Depth � Set in oversize hole? Annular space initially grouted?
PropeAy owner's mailing address'rf di8erent than well location address indicated above ��
� in.from� t0��ft. ❑Yes �No ❑Yes ❑No ❑Unknown
1315 �iarns St, Ste 1
a7tiG.R�}�� MN 55379 in.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.ffom to ft. ❑Yes ❑No ❑Yes ❑No � ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE �
�/�/
We��owner's mailing address it different than properry owners address indicated above Sc�een f�Orp�S„dL—to_��ft. Open Hole frOn1 t0 ft.
i, OBSTRUCTIONS
` Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction '
� � r/•--
; � ��
Type of Obstructions(Describe)�bS+�y!�_��''��f 4 l! � /
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ No Desc�ibe
FORMATION
If not known,indicate estimated formation log irom nearby well or boring PUMP
, Type
1J
� ❑ Removed �Not Present ❑Other
f 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 PeAoration/Removal
in.from to ft. ❑ Pertorated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonRe=50 Ibs.)
(
Grouting Matenal� �m�_to� yards � bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFlCULTIES 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.
T1on Stodala '6�I1 Drii i
Contractor Business Name � License or Regisha6on No.
_ D'�
h en ive nature/ Date
LOCALCOPY
H2�6757 "� �'�°'�'
Name ol Person Sealing Well or Boring