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IDN 53159 11/19R <br />MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br />WELL AND BORING SEALING RECORD Sealing No. <br />Minnesota Unique Well No. <br />Minnesota Statutes, chapter 1031 or W Sen es�No. <br />H `� 8 1552 J— <br />J 5 5 2 <br />WELL BORING LOCATION <br />Na <br />County Name <br />Tenn@ itT <br />Township Name <br />row <br />Township No. <br />117 <br />Range No. <br />23 1 <br />Section No. <br />17 <br />Fraction (sm. - Ig.) <br />1WTA S7 <br />Date Sealed <br />1 <br />Date Well or Boring Constructed <br />GPS LOCATION — decimal degrees (to four decimal places) <br />Latitude Longitude <br />Depth at Time of Sealing1 i�ft. <br />Original Depth ft. <br />• - <br />AQUIFER(S) <br />Single Aquifer ❑ Multiaquifer <br />STATIC WATER LEVEL <br />t <br />Date Measured `� • ❑ Estimated <br />I <br />ff <br />lr ft. Ixtielow ❑ above land surface <br />NumericalStreet <br />i7Address or Fire Number and City of Well or Boring Location <br />. 3 <br />2205 ,,� M{Measured <br />�L <br />WELL/BORING <br />Water -Supply Well ❑ Env. Well <br />❑ Temp. Boring ❑ Other <br />Show exact location of well or boring Sketch map of well or boring <br />in section grid with "X:' location, showing property <br />N lines, roads, and buildings. <br />1� <br />I t I �y <br />--i--- --A-- ---F-- ---l-- ! SFX, <br />777777 <br />W ET <br />f _ I I- I <br />'h Mile <br />S <br />1 Mlles <br />For tempolary borings, provide additional location <br />information, a site sketch, and geology on a separate page. <br />CASING TYPE(S) - <br />(�-Steel ❑ Plastic ❑ Tile ❑ Other <br />WELLHEAD COMPLETION - <br />Outside: ❑ Pitless Adapter/Unit [I At Grade Inside: Basement Offset <br />❑ Well Pit ElBuried -1 Well House <br />El Other El Well Pit <br />❑ Buried <br />❑ Other <br />CASING(S) <br />Diarrteler Depth Set in oversize hole? Annular space initially grouted? <br />� in. from ' to '- J, ft. ❑ Yes ❑ No ❑ Yes ❑ No jXunknown <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Boli Ness <br />Property owner's mailing address if different than well location address Indicated above <br />SCREEWOPEN HOLE <br />+ LT <br />Screen from ` =�1,--)3 to 5: ft. Open Hole from to ft. <br />WELL OWNER'S NAME/COMPANY NAME <br />OBSTRUCTIONS <br />M Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />Type of Obstructions (Describe) f `r <br />Obstructions removed? es ❑ No Describe <br />Well owner's mailing address it different than property owners address indicated above <br />PUMP <br />❑ Not Present aPresent, Removed Prior to Sealing ❑ Other <br />Type <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TO <br />If not known, indicate estimated formation log from nearby well or boring. <br />t <br />{ <br />a <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 />'Casing 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 KNo TNN <br />GROUTING MATE IAL(S) <br />(� f <br />Grouting Material from to V / ft. yards •-It 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 P"o 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 />Don Stodols I -Tell Drilling Co 1691 <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />Licensee Business Name License or Registration No. <br />3j L 1 <br />'Certified hepresentafive Signature Certified Rep. No. Date <br />Ae <br />LOCAL COPY <br />H 3 5 5 2 <br />ng <br />Name of Person Sealing ell or boring <br />IDN 53159 11/19R <br />