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p <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennle oNa Unique Well No. <br /> � Minnesota Statutes,Chapter f031 or W-series No. <br /> (Loaw denk M nal lapwii) <br /> y Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Weli or Boring Conslructed <br /> G�rOnd 117 23 �7 3�-��t0$'" _ /r�: <br /> Lati[ude de rees minutes seconds <br /> GOCATION: 9 Depth Betore Sealing � ��--k. Original Depth ' J ft. <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 ..Mul�aqurfer <br /> WELUBORING - [�Measured ❑Estlmated <br /> ater Supply Well ❑Monit.Well <br /> Show exact location of well or boring �Sketch map o well or ring � <br /> Env.Bore Hole Other � -� ft. [�below ❑above land suAace <br /> in section grid wfth"X" I ation,showing property ❑ ❑ <br /> lin s,roads,and buildings. � <br /> N 7 CASING TYPE(S) <br /> d% <br /> �� 't, ❑Steel �'lastic ❑Tile ❑Other <br /> ,. <br /> W —h- - -- -=-- --=-- E / WELLHEAD COMPLETION <br /> � � � - Outside: ❑Well House Inside: ❑Basement Offset <br /> _Y_ ____ _l__ __�__ <br /> � !}mib ��' j �,'Pitless AdaptedUnit ❑Well PR <br /> --�- -�-- -i-- --�-- I � �. <br /> ' ' ' ' � ❑Well Pit ❑Buried <br /> �, <br /> �—�^"w—� . '\ � ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME ��, CASING(S) <br /> � � � Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> PropeAy owner's mailing address'rf different than well location address indicated above � . <br /> in.from �to �� ft. ❑Yes �(No ❑Yes ❑No ❑Unknown <br /> �420 Shareline Dr � <br /> Sprin�r C�rR � �'�� �.7�7pq �n.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.f�om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> � WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> Well owner's mailing address if ditterent than property owner's address indicated above SCf@0f1 ffORl � t0 �� � � ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill �IVo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑YBS ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> , �„ - TYPe <br /> '"� = � ❑ Removed C�Not Present ❑Other <br /> 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 PeAoration/Removal <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 bentonite=50 Ibs.) <br /> Grouting Matenal � ����fienf` to ` ft. yards � bags <br /> i� <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 propeAy? ❑ Yes ❑ No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Cnapter 4725.The infortnation contained in[his report is <br /> true to the best of my knowledge. <br /> z�an �tc�dot At wet � n�3 � lix���Cc�-. I�c.. 2.7� 72 <br /> Contractor Business Name -. �nse or Registrahon�o. <br /> __ ,: <br /> .__..___ ' /' <br /> �-` !�-...�' �- � <br /> ho d res tat e Signatu Date <br /> ' � <br /> ������+� � ._,. ,. ,,._. .,.'-ti <br /> H __� _ , <br /> LOCAL COPY <br /> Name of Person Sealing Well or Borirrg <br />