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Well and Boring ' I :J <br />WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing Minnesota C� B ^i , j 5 <br />County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. C� <br />Minnesota Statutes, chapter 1031 or-s�e9ies No. <br />-t k—) <br />T <br />Township a e <br />Township No. <br />Range No. <br />Section No. <br />Fraction (sm. -+ Ig.) <br />Date Sealed <br />Date Well or Boring Constructed <br />GPS LOCATION - decimal degrees (to four decimal places) <br />Depth at Time of Sealing 8 7 ft. <br />Original Depth ft. <br />Latitude Longitude <br />AQUIFER(S) <br />Pq Single Aquifer ❑ Multiaquifer <br />STATIC WATER LEVEL <br />) t ! / �f <br />� Measured Date Measured 1.1 J 2 2 ❑ Estimated <br />6 2 [Xbelow El above land surface <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />1525 Minnie Ave "Ipund rPT 55361% <br />W ELLBORING <br />Water -Supply Well Env. Well <br />❑ Tem Boring Other <br />p 9 ❑ <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 />CASING TYPE(S) <br />KI Steel ❑ Plastic ❑ Tile ❑ Other <br />--;--- --�--- ---r-----�--. _ -• <br />WELLHEAD COMPLETION - <br />W-- - --. - <br />I f <br />'k Mile <br />1 <br />Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: Basement Offset <br />El Well Pit E] Buried Well House <br />EJ Well Pit <br />❑ Other <br />❑ Buried <br />I— —t Mlle <br />❑ Other <br />For temporary borings, provide additional location <br />information, a site sketch, and geology on a separate page. <br />CASINGS) <br />Diameter Depth Set in oversize hole? Annular space'initially grouted? <br />2 In. from 1 to 8 3 ft. ❑ Yes ❑ No ❑ Yes ❑ No [Unknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />?Kari. DuenQW <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />Property owner's mailing address if different than well location address_ Indicated above <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />SCREEWOPEN HOLE <br />Screen from__8 3 to � 7 ft. Open Hole from to ft. <br />WELL OWNER'S NAME/COMPANY NAME <br />OBSTRUCTIONS <br />lk Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />Well owners mailing address If different than property owner's address Indicated above <br />Type of Obstructions (Describe) drop 1:D+> <br />Obstructions removed? EkYes ❑ No Describe <br />PUMP <br />❑ Not Present ® Present, Removed Prior to Sealing ❑ Other <br />Type- jP F ) I I rn t) <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 />METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />E*No Annular Space Exists ❑ Annular Spare 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 ® No TN# <br />GROUTING MATERIAL(S) <br />Grouting Material Neat Cement from 1 to 87ft._yards 2 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 ® 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 />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />non !:;t'o,jol i Nal m i l l ink rn Inc 1691 <br />Licensee Business Name License or Registration No. <br />/,f / //� 55`� !,/1�,M <br />z z / <br />Certi#ed.l' 06sentative Signature ` Certified Rep. No. Date <br />Jerry Barr <br />LOCAL COPY H i )H <br />Name of Person Sealing Well or Boring <br />HE -01434-17 ID# 53169 <br />11/19R <br />