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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I ��O�O� <br /> County Name" <br /> WELL AND BORING SEALING RECORD Mennlesoa�Unique Well No. <br /> }� }� Minnesota Statutes,Chanter 1031 or W-series No. <br /> {�•pDep i Y r (Leave blenk If not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> zono 11� 23 07 �� �� �� �} <br /> , <br /> GPS Latitude degrees minutes seconds Depth Before Sealing �y ft. Original Depth ft. <br /> � LOCATION: Longitude degrees minutes seconds <br /> A IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ]Multiaquifer ��1 ,�� /��� t <br /> 4196 l�orth Shore asi OrOAD I ris�• �/UBORING Measured [J Estimated Date Measured �f'� _ '.d' <br /> �jWVater-Supply Well ❑Monit.Well . <br /> Show exact location of well or boring ketch map of well or boring <br /> in section grid with"X" location,showing property ❑Ern.Bore Hole ❑Other �ft. �below �J above land surface <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> � --'--- --'-----`-- ---'-- <br /> ^ -`�t� Steel ❑Plastic ❑Tile ❑Other _ <br /> a\!' <br /> --'-----�------`- --"'` WELLHEAD COMPLETION � <br /> W ; � � : ET <br /> � � � � Outside: ❑Well House �]At Grade Inside: �7psasement Offset � <br /> - -------- - -- - �� <br /> _ � � __� _ _ ;. <br /> � � � � M'�e itless A p dUnd ❑Buried [.]Well Pit <br /> 'h � ❑P' da te " <br /> ._ --.-- --,-----.-- --:- l <br /> ❑Well Pit ❑Buried <br /> S <br /> ❑Other <br /> �1 Mile� ❑OthBf <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASMG(S) <br /> Diameter� r Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different ihan well location address indicated above � /� <br /> Z in.from�7 to�ft. �J Yes �(Vo ❑Yes ❑No ❑Unknown <br /> 76��370�41�Q in.from to ft. ��Yes ❑No ❑Yes ❑No ❑Unknown � <br /> : in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � / <br /> Well owner's mailing address ii ditterent than properry owner's address indicated above SCreen ffOm �"" to � r ft. Open Hole hom to__ _ft. <br /> - �TRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) �.]Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)r„��/L.�� i"�`„f��. d` `+�� __ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? es ❑No Describe <br /> FORMA710N <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> � � Type <br /> f []Removed [�Vot Present ❑Other „__ <br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> (�lo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe U Casing Perforation/Removal <br /> in.from to _ft. ❑Perforated (J Removed <br /> � in.from to ft. ❑Perforated [J Removed <br /> Type ot Perforator____ . _ <br /> ,_,Other_ ,._._ <br /> GROUTING MATERIAL(S) (One bag of cement=94 las.,one bag of bintonite=50 Ibs.) <br /> Grouting Material�'C�� C��.f/�/�f/�m � to ` � ft. yards � bags <br /> from to ft. yards bags <br /> �. from to ft._ yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? []Yes No 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 <br /> is true to the best of my knowledge. <br /> D4H STODQLI! MFLL DBILLIW�i CO..,. IliC._ 1691 <br /> Licensee Business Name License or Registration No. <br /> ,,- ` ' _ 558 ,��� �;:X; <br /> t 'd� �es� tative Signatu� Certified Rep.N¢ � Date <br /> �,, �..i,'��-r._/��,,� '. <br /> LGCP,LCGFY H �lOZO� S <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-10 IC#140-0423 ! , sio7a '. <br />