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_. .. ... �v. . . _. ._ <br /> _ _�.�<.�.� <br /> ,' WELL OR BORING�OCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I <br /> County Name <br /> WELL AND BORING SEALING RECORD Minn'esota Unique Well No. <br /> Minnesota Statutes,Chapter f031 or W-series No. <br /> t�eeVe ae�t n�a�own� <br /> Township a Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> OLO[l0 �.1� ��. �� ��. (J�j Q <br /> GPS Latitude degrees minutes seconds C,� � <br /> LOCATION: Depth Before Sealing � y3� ft. Original Depth (t. <br /> Longi[ude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> + Numerical Street Address or Fire Number and City of Well or Boring Location Single Aqu'rfer ❑Multiaquifer <br /> WELUBOR�NG �Measured ❑Estimated <br /> �Vater Suppty Well ❑Monit.Well � <br /> S ow ct I� ` o rin � Ske ell or n <br /> in section grid with"X" location,showing pro ❑Env.Bore Hole ❑Other �D ft. elow ❑above land surface <br /> lines,roads,and buildi g . <br /> N - -- CASING TYPE(S) <br /> _ _ _Y_ _ __ _ __ � <br /> {l <br /> T , P' Steel ❑Plastic ❑Tile ❑Olher <br /> w --F- - -- - -- --;-- E � � WELLHEAD COMPIETiON <br /> � ' � ! y <br /> � � Outside: ❑Well House Inside: ❑Basement Offset <br /> -;r- ---- -+- -i— 7{y <br /> 1�� J �'��` �Pitless AdaptedUnit ❑Well Pit <br /> --�- -�-- -i-- --i-- I � '� <br /> 1 ❑Well Pit ❑Buried <br /> S <br /> �—""'�—�' ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diame er� / � Depth J Set in oversize hole? Annular space initially grouted7 <br /> Prope owner s mai ing a ress i itteren ihan wel oca ion a ress dicated above ,�,`' <br /> � in.ffom� to_��. ❑Yes �vo ❑Yes ❑No ❑Unknown <br /> 7\ <br /> in.ffOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> � in.ffOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> i � t <br /> Well owner's mailing address if diNerent than properry owneYs address indicated above Screen from t0 ft. Open Hole from�20�ft. <br /> OBSTRUCTIONS <br /> `dRods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> J� /� <br /> Type of Obstructions(Describe) ��/V��.,,�� � �U�/� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM 70 Obstructions removed? es ❑ No Describe <br /> FORMATION <br /> If no[ own,indicate estlmated formation log irom neaiby well or boring PUMP <br /> 7Ype ��..�� �(1f�� <br /> Removed ❑ Not Present ❑Other <br /> f � � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> y�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 /> a ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material���/ �'��,eCI �Arom�—to.�.].S.iI.' yards � bags <br /> ` from to ft. yards bags ; <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SJURCE OF DATA,DIFFICULTIES 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 infortnation contained in this report is <br /> true to the best of my knowledge. <br /> I3o� Sta�ola �?elI Drillin� Co., Tnc. Ih�31 <br /> Contractor Business Name License or Registration No. <br /> ''�J ^. '�.�✓i i,...'� <br /> A n d S' Date <br /> LOCAL COPY H S 1 ( �iJ '. . _ �;,:..,..:r..ir;�,-�..r.,. <br /> Name ol Person Sealing Well or Boring <br />