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- <br /> wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. <br /> , or W-series No. <br /> He r►n e i n Minnesota Statutes,Chapter 1031 ������k��a�� <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constnicted <br /> � <br /> orot�o 217 23 lU 3i�- �98'' � <br /> . <br /> GPS �etitude degrees minutes seconds 24 � <br /> LOCATION: Depth Before Sealing ft. Original Depth (t <br /> Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer �/ <br /> WEI UBORING Id7�7easured ❑Estimated <br /> ��� �Water Supply Well ❑MoniL Well � <br /> . Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" location,showing pr rty ❑Env.Bore Hole ❑Other �� ft. �below ❑above land surface <br /> N �J�J�g 1�'Tin�,�ds.an 9S� CASING TYPE(S) <br /> } <br /> � �Steel ❑Plastic ❑Tile ❑Other <br /> W --�- - - �-- —i— E WELLHEAD COMPLETION <br /> � � � � <br /> � Outside: ❑Well House Inside: Basement Offset <br /> � <br /> __f_ __ _ _1__ _j__ <br /> 1�� ❑Pitless AdaptedUnit ❑Well Pit <br /> --�- -f- -i-- --�— I <br /> 1 ❑Well Pit ❑Buried <br /> - �!�—rm�s-�. ,/ Buried <br /> � fI :`±''��,,�r.. �'..:.z �� � ���'.;J j=G�G'1.JI��+�%CCI <br /> � PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> . Diameter �Depth � Set in oversize hole? Annular space inifialty grouted? <br /> � Property owner s m� ng ad ress i � eren an wel dd cated above � / �� <br /> j _�_ in.ffOm�_ t0��ft. ❑Yes 'J�No ❑Yes ❑No ❑Unknown <br /> 1409 S. 7tin St. 952-935 55'5$ <br /> �0�liLillS/ �N rJr3343 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> j' in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknawn <br /> ' WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> �7'1 / f <br /> we��owner's mailing address'rf diHerent than property owners address indicated above SCfeen ffom�t`�to��ft. Open HoIB frOrit to ft. <br /> � OBSTRUCTIONS <br /> `�Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe)�,�J��,/�„{�= �L��li .r� <br /> - GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? @S ❑ NO DBSCfIbe <br /> FORMATION <br /> If not known,indicate estimated formafion log irom nearby well or boring PUMP <br /> Type <br /> �"''' ' r ��� Removed ❑ Not Pres nt ❑Other <br /> < <br /> �i � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �fJo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> / ' <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonRe=50 Ibs.) <br /> r� � � <br /> Grouting Material��(i r�✓'✓�r'f=.,Yf.c. ��om�_to��ft. yards _� bags <br /> from to ft. yards bags <br /> irom to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING pther unsealed and unused well or boring on property? ❑ Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Contractor usiness ame L� nse s tion No. <br /> __ � ,�� - - i ;1!� <br /> A �'eAR resentative Signa re ""� Date � <br /> ,�,'� __. =: <br /> \ � �� <br /> LOCAL COPY H �914 3 �{- <br /> .�... ✓r �,..a��.�. <br /> Name ol Person Sealing Well or Boring . � <br />