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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I <br /> County Name WELL AND BORING SEALING RECORD Sling M nneso aoUnique Well No. - <br />` Minnesota Statutes,chapter 1031 or W-series No. <br /> P {Leave blank if nod known) <br /> 1l� t+1� ../�t <br /> Township Name Township No. Range No. Section No. Fraction(sm.— lg.) Date Sealed Date Well or Boring Constructed <br /> Ott Oil 0 117 23 04 A i,v ioj 4.6 % 11/22/22 <br /> GPS LOCATION—decimal degrees(to four decimal places) bb <br /> Depth at Time of Sealing ft. Original Depth ft. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location a Single Aquifer ❑Multiaquifer <br /> 2760 C O N , .S S I D E R.w. 'L O iy WELL/ A Measured Date Measured 1 1/�2 2/2 2 ❑Estimated <br /> 11 Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring/ALL g�1t sq pi wwyy ��pq g <br /> in section grid with"X." Rr Ideal- shAITfg l ftyn ❑Temp.Boring ❑Other b 7 ft. ®below ❑above land surface <br /> lines,roans,and buildings. <br /> N CASING TYPE(S) . <br /> , ❑Steel AI Plastic ❑Tile ❑Other <br /> / ,. <br /> WELLHEAD COMPLETION <br /> . I-------T__ Outside: X Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> Mil ❑Well Pit ❑Buried ❑Well House <br /> , — r . - <br /> ❑Well Pit <br /> ❑Other <br /> S ❑Buried <br /> I-1 Mile <br /> ❑Other <br /> For temporary borings,provide additional locati CASING(S) - <br /> nformation,a site sketch,and geology on a seta to page. Diaeter Depth? Set in oversize hole? Annular space initially grouted? <br /> PRRPPFTY /NER' fA[ EOr .�4Yt1VP/) in.from I to ft. ❑Yes ❑No ❑Yes ❑No A Unknown <br /> Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEN/OPEN HOLE <br /> Screen from 177 to 186 ft. Open Hole from to ft. <br /> WELL OWNER'S NAME/COMPANY NAME . <br /> J ON Mt ivioLli if S. E k ii OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above IX Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> PIPE , <br /> Type of Obstructions(Describe) ' <br /> Obstructions removed? Lj Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present ]Present,Removed Prior to Sealing ❑Other ' <br /> If not known,indicate estimated formation log from nearby well or boring. S U8 &S BLE <br /> Type <br /> DRIFT1 112 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 ❑No TN# <br /> GROUTING MATERIAL(S) <br /> NEAT Grouting Material C t �d`t from to 1 <br /> 186 ft. yards 16 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 /> 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 /> DON 0 1 L WELL DRILLING CO. 1691 <br /> Licensee Business Name License or Registration No. <br /> / , 558 11/22/22 <br /> Certified Representative Signature Certified Rep.No. Date <br /> H JERRY BARK <br /> LOCAL COPY 3 9E O Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />