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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring o. H 397016 <br /> County Name WELL AND BORING'SEALING RECORD Sealing Na Unique Well No. <br /> Minnesota Statutes,chapter 1031 or W-series No. <br /> y y jy y^..j� P (Leave blank,f not known) <br /> Township Names Township No. Range No. Section No. Fraction(sm.—.lg.) Date Sealed Date Well or Boring Constructed <br /> OiCuSIUU 117 23 U4 A AWSE '' 9/15/22 <br /> GPS LOCATION—decimal degrees(to four decimal places) 109 <br /> Depth at Time of Sealing ft. Original Depth ft. <br /> Latitude... Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location [Single Aquifer ❑Multiaquifer <br /> Y WELL/BORING 3 Measured Date Measured 9/15/22 ❑Estimated <br /> t7uU ftlTh UA1� CIRCLE„ �i��}I�IU, Water-Supply Well El Env.Well <br /> Show exact location of orfrib1ial S'b Sketch map of well or boring <br /> in sebtion grid with"X. location,showing property LI Temp.Boring ❑Other 51 ft. [Ibelow ❑above land surface <br /> I' a ,roads,and buildings.N CASING TYPE(S) <br /> ,. Al Steel ❑Plastic ❑Tile ❑Other <br /> •--___ --•--- --- WELLHEAD COMPLETION <br /> w ET <br /> ____ I Outside: ®Pitless Adapter/Unit El At Grade Inside: El Basement Offset <br /> h Mile ❑Well Pit ❑Buried ❑Well House <br /> -- --- i r --- I ❑Well Pit <br /> I i 1 r( ❑Other s <br /> ❑Buried <br /> 1 Mile ❑Other <br /> For temporary borings,provide additional location . CASING(S) <br /> information,a site sketch,and geology-On a separate age. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME / in.from to 1 05 ft. ❑Yes ❑No ❑Yes ❑No ®Unknown <br /> LUS T Ur ONE AUAES, LLU 7'` <br /> Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> bSt rIUEMliEitG f1i #103 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WOODBUSY, 4N 55125 <br /> SCREEWOPEN HOLE <br /> Screen from 1 05 to 109 ft. Open Hole from to ft. <br /> WELL OWNER'Syy� NAME/COMPANY NAME !� <br /> C0 iUA UNE Lce AA S, LLC OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above A Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> DROP PIPE <br /> Type of Obstructions(Describe) <br /> Obstructions removed? 4Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present�t Present,Removed Prior to Sealing ['Other <br /> If not known,indicate <br /> 10 <br /> iindicate estimated formation log from nearby well or boring. i �q Type SUBMERSIBLE <br /> DR/i ♦ 1 9 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> [A 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 A No TN#_ <br /> GROUTING MATERIAL(S) <br /> svi AT CEMENT 1 109 9 <br /> Grouting Material from to ft. yards 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 EI No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 /> DOA STUDGLA WELL Cu 1691 <br /> Licensee Business Name License or Registration No. <br /> ,,� ,� 55t3 9/15/22 <br /> - ur . f <br /> e epresentative Signs ure Certified Rep.No. Date <br /> JER RY 13ARR <br /> LOCAL COPY H 3 9 7 016 Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />