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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 3 4 6 9 1 9 <br /> WELL OR BORING LOCATION Sealing No. H <br /> County Name z WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> 1 t:it it C:(�1 ii P (Leave mask a no known) <br /> ..,/ . / <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) Date Sealed Date Well or Boring Constructed <br /> vraetp 217 d.i 17 ' v <br /> ., . ._. ..i,: 5/5-/i7 <br /> GPS LOCATION—decimal degrees(to four decimal places) / 0 <br /> f <br /> Depth Before Sealing /‘ ft. Original Depth ft. <br /> Latitude Longitude <br /> A UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ,�1 /�,/�y.,/ <br /> W L/BORING -X Measured ❑Estimated Date Measured T/-;'�l4 r}/4/ <br /> ,1 )i I LILL.V` t h V`: U r fa n© • Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or oring �? <br /> in section grid with"X." location,showing prop rty ❑Env.Bore Hole ❑Other EJ ft. )4 below ❑above land surface <br /> lines,roads,and buildi g <br /> N CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> ---I------I-----'t----'-"' 11,, <br /> WELLHEAD COMPLETION <br /> w : E <br /> } T_ __ I 141 7 Outside: ❑Well House ❑At Grade Inside: Basement Offset <br /> h Mile ❑Pitless Adapter/Unit ❑Buried ❑Well Pit RECEIVED <br /> --- <br /> - ---------- - - <br /> 1 <br /> ❑Well Pit ❑Buried <br /> I 1 Mile ❑Other ❑Other juN 13 2011 <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Jd Dia e;ero f Depth 5'7 f Set in oversize hole'? t' rO IF-(jt h/' 'Qi d? <br /> Property owner's mai?fr ad esslf dl erert�'4han well location address indicated above in.from (1 to l ft. ❑Yes )(No ❑Yes ❑No ❑Unknown <br /> G i 10 J it e a y r 1 il e £,J2 a e in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> rueathaoiiie, WI. 54751 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> s / I <br /> Well owner's mailing address if different than property owner's address indicated above Screen from F ;0/ <br /> Well ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)..._,/L/AJ4'S/< ,01-1*.. i UM� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Xes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. [('�� <br /> nj////^���� / Type �e �mf <br /> , 6 /(L$/ Vemoved ❑Not Present ElOther <br /> 1 <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ><No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes j��, No TN# <br /> GROUTING MATERIAL(S) (One bag of cement w 54 lbs.,one bag of bentonite=50 lbs.) <br /> P f <br /> w� <br /> Grouting Material f�r4.476144 from to /4 1 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 /> .1..“../.1 ,...,1u✓i)I.IA 41,1_444 uK.ZL141.jYLr t..:.J• , .L G• 107'1 <br /> Licensee Business flame License or Registration No. <br /> i / <br /> tertified eR p�ntative Signature Certified Rep.No. Date <br /> " 346919 a ,� �- -0 <br /> LOCAL COPY 1 Name of Person Sealing Well or Bc <br /> HE-01434-14 1D#53159 5/13R <br />