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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H `� � �� County Name WELL AND BORING SEALING RECORD M nnleso a�Unique Well No. �l " Minnesota Statutes,Chapter 103! or W-series No. (Leave blank�il no�known) T TtlW Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed v. ,i v. G ION- decimal egrees(to fo`ur decimal p aces) " � Latitude Longitude_ Depth at Time of Sealing �f� ft. Original Depth ft. AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �,,/ ", WELL/BORWG Measured Date Measured��)f1r1� �!_ ❑Estimated 17bC� �oreline >�r, ?�(af'IO 553�1 Water-Su I Well pp y ❑Monit.Well � Show exact location of well or boring Sketch map of well or boring 7 in section gnd with"X:' location,showing property Ern.Bore Hole ❑Other ��_ft. �below ❑above land surface lines,roads,and buildings. :; N �.,•--..._ , CASING TYPE(S) . r� . : � � � � � . --'--- -i-- --`- --'- ..;... �%� Steel ❑Plastic ❑Tile ❑Other '� --'--- --'--- ---�-----`- 3 �= „��T� WELLHEAD COMPLETION - �, W I I I I E i [ � I I I IO ::.,� ��c�rv�� __;____;_____�_____;__ T i �a�� Outside:�Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset '�M� �fS�y ❑Well Pi[ ❑Buried ❑Well House /� �J ❑Well Pit �� 7 �v�/ S ❑Other _ ❑Buried ^. �1 Mile n ❑Other Ci�N�F�RQN�_ �� ._ . .__,... .. �.�,. , PROPEFTY OWNER'S NAME/COMPANY NAME CASING(S) Diam t�r � Depth � Set in oversize hole? Annular space initially grouted? W` o �ilin !if diNerent ihan well location address indicated above � �in.from 0 to f/2 ft. ❑Yes �No ❑Yes ❑No ❑Unknawn �� 7�..V }�+,,�t L$Rc �J't� ��13 in.from to ft. ❑Yes C]No ❑Yes ❑No ❑Unknown ` tdayzata, ��I 5539I , � in.from to ft. ❑Yes ❑No ❑Yes �:�j No ❑Unknown � WELL OWNER'S NAME/COMPANY NAME SCHEEN/OPEN HOLE / ♦ i ? Well owner's mailing address it ditterent than property owner's address indicated above Scfeen from //2. to�L�ft. Open Hole(rom t0 ft. i OBSTRUCTIONS � �i _; ❑Rods/Drop Pipe ❑Check Valve(s) ��Debris ❑Fill �No Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION PUMP � If not known,indicate estimated formation log from nearby well or boring. . Not Present ❑Present,Removed Prior b Sealing ❑Other � _.. � i� Type ��! METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE �o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal sing Diameter . in.from ,_to fL [�Perforated ❑Removed +� in.from to ft. �-J Perforated ❑Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# GROUTING MATERIAL(S) (One bag oi cement= 4 Ibs.,one bag of bentonite-50 Ibs.) i / � GroutingMaterial/(�F_ IQT�'L/n��/ from U to f/C.0 ft. yards�Q bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? [�Yes No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. ?x�n "toclola t�ell �rillin�; Co,. Inc. I692 Licensee Business Name License or Registration No. . ,, _,!_.. �, - :�-'''�f� �. �-:; � 7 _ ��- Cpriified Reprc�sent�Signattir�� Certified Rep.No. Date � n -�-�- LOCAL COPY H � � �-•� -�- � - ' �,, _�z.,�-, .� � ��2 6 7 Name ol Person Sealing Well or Boring � HE-01434-15 ID#53159 an6R