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HE -01434-17 ID#53159 N- '— 11f19R <br />MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br />H 38148 <br />OR BORING LOCATION <br />WELL <br />Sealing No. <br />WELL AND BORING SEALING RECORD Minnesota or W -series UniquNo. e Well No. <br />Minnesota Statutes, 1031 <br />Q <br />County Name <br />L/ r <br />� <br />chapter (Lem blank Bnor k,wm) <br />7 � •� <br />Township Na a <br />Township No. <br />Range No. <br />Section No. <br />Fraction (sm. -� Ig.) <br />Date Sealed <br />Date Well or Boring Constructed <br />21 <br />GPS LOCATION - decimal degrees (to four decimal places) <br />t r <br />l <br />�r� <br />Depth at Time of Sealing ft. <br />Original Depth I ft. <br />Latitude Longitude <br />AQUIFER(S) <br />Single Aquifer ❑ Mulliaquifer <br />STATIC WATER LEVEL <br />j '7 <br />Measured Date Measured ! _:4 ` _%� ..� `�❑ Estimated <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />ELUBORING <br />IM L<)mR Linda. Oril 1 <br />['Water -Supply Well ❑ Env. Well <br />Show exact location of well or boring Sketch ma of well or boring <br />in section grid with "X:" locat�o , of, <br />property <br />❑ Temp. Boring ❑ Other <br />j m i <br />f ft. [below El above land surface <br />N li 11 adts buildings. <br />111 <br />CASING TYPE(S) <br />3y <br />Steel ❑ Plastic ❑ Tile ❑ Other <br />------ ------ ---F-- ---t-- <br />W E�--i__• -_r-_ __ �__ ___�__ �-A '� ' �- . � <br />WELLHEAD COMPLETION - <br />Outside: RdPitless Adapter/Unit ❑ At Grade Inside: ❑Basement Offset <br />,� �h <br />Mile . <br />E] Well <br />❑ Well Pit ❑ Burred House <br />r= 1 <br />❑Well Pit <br />S <br />❑ Other <br />❑ Buried <br />I Mile <br />- ❑ Other <br />For temporary borings, provide additional location <br />CASING(S) <br />information, a site sketch, and geology on a separate page. <br />Diameter Depth T] Set in oversize hole? Annular space initially grouted? <br />in. from to / / c1 ft. F1 Yes 'VNO ElYes ElNo ElUnknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Pei StD <br />in. from to ft. El E]No ❑Yes ❑ No ' ❑ Unknown <br />Property r'sr y ownemailing address if differen t an well location address Indicated above - <br />t7ier <br />4.2 Lily Lane <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />Minnetrista, NN 55331 <br />SCREENIOPEN HOLE <br />Screen from { 7 0 to f L? jt. Open Hole from to ft. <br />WELL OWNER'S NAME/COMPANY NAME <br />OBSTRUCTIONS <br />Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill. ❑ No Obstruction <br />Well owner's mailing address if different than property owner's address indicated above <br />Type of Obstructions (Describe) �) - <br />Obstructions removed? VYes ❑ No Describe <br />PUMP <br />Present [Present, Removed Prior to Sealing El Other <br />❑ g <br />Type�4t- <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TONot <br />If not known, indicate estimated formation log from nearby well or boring. <br />METHOD U§ED 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 />asing Diameter <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 XNo TN# <br />GROUTING MATERIAL S) <br />13 ,,� <br />Grouting Material _ rY� ( 0 from- 6 to / Vi ft. yards 1 bags <br />from to ft_ yards bags <br />from to ft. yards bags <br />OTHER WELLS AND BORINGS <br />Other unsealed and unused well or boring on property? ❑ Yes yNo 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 />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />is true to the best of my knowledge. <br />Don Stodola Moll Drillimco., Tne. Z6C)l <br />Licensee Business Name License or Registration No. <br />f <br />Certil%ed Pepresenfative Signaft(ey R -- Certified Rep. No. Date <br />LOCAL COPY <br />H 8 Li. 3 <br />Name of Person Sealing Well or Boring <br />HE -01434-17 ID#53159 N- '— 11f19R <br />