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WELL OR EORING LOCATION MINNESOTA DEPARTMEN7 OF HEALTH Minnesota Well and Boring I„I ����C C <br /> Counly Name <br /> WELL AND BORING SEALING RECORD Minn�e90 a�Unique Well No. v V <br /> Minnesota Statutes,Chanter 1031 or W-series No. <br /> �"' �Leeve blenk'il no�knownJ <br /> { Township Nam Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Construded <br /> � <br /> �� � �� � �.r o <br /> , <br /> GPS Latitude degrees . _ minutes.__ __ seconds Depth Before Sealing �� ft. Original Depth _ft. <br /> ��� LOCATION: Longitude degrees_ minutes__.__. seconds �� <br /> �UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location ,. Single Aquifer [�Multiaquifer �fn.� A/1 <br /> WELUBORING _;Measured [�Estimated Date Measured.�!""!"� `.lI'�� <br /> 1 .]Water-Supply Well [�MoniL Well � <br /> Show exact location of well or boring Sketch map of well or boring i Env.Bore Hole � �I Other f ft. �j below above land surface <br /> in section qrid with"X:' location,showing property �- — � U <br /> lines,roads,and buildings. -� <br /> : N CASING TYPE(S) <br /> :. _L— —'-- --`--'—'- n;t <br /> tr�j}1�h�� �� ���� ��Steel �Plastic [Tile _j Other _ _ <br /> !� <br /> ' --�--- --�--- ---`-----'-- WELLHEAD COMPLETION �� <br /> . W , ET _ <br /> ; ; ___ __ r__ Outside: j]Well House _At Grade Inside: �Basement Offset <br /> i <br /> 'h M��e P�� � �� ;,�Pitless AdaptedUnd `:Buried ❑Well Pit <br /> A --,--- --.--- ---�-----:-- 1 � _ <br /> _,�Well Pit ❑Buried <br /> S ❑Other <br /> �-1 Mile—� ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Qj�jl,f� � Diamet�,r� + Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location atldress indicated above S � t� u � I� n ��Unknown <br /> in.from to ft. Yes No Yes No <br /> in.from to ft. ❑Yes ❑No ❑Yes �f No [_.Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No [Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> � r <br /> � <br /> S Well owner's mailing address if different than property owr,er's address indicated above SCreen from___��� to__�� R. Open Hole from____,___ _ _to __ ft. <br /> OBSTRUCTIONS <br /> ��._.J Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction �� <br /> 5 <br /> '� Type of Obstructions(Describe) ' <br /> GEOLOGICAL MATERIAL COLOR HARDNESS oa FROM TO Obstructions removed? ❑Yes C No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate esfimated formation log from nearby well or boring. <br /> ; � . 1 ^� TYPe `, <br /> �� /�r- �J ..;)vC .� ; <br /> .�� �. J Removed '��,Not Present �, �..Oiher____.___._______________.___ ! <br /> METHOD USEDTO 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 /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other <br /> . GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material f���% �F J�.L��rom_�• to J� I ft. yards� bags <br /> _,___ from _ to___ ft. yards bags <br /> from _ to ft. _ yards_ bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES iN SEALING 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 /> � �n_�_totala ieiell Drilling_ Co---- --1691 ----- : <br /> Contractor Business Name License or Registration No. <br /> . � . �'�' i.'��- �i� � <br /> i epresentative Signature� �� � Certrfied Rep.No. Date <br /> ,ti <br /> LOCAL COPY H 2 616 6� ��;�Y� -��f`��YY� <br /> Name of Person Sealing Wel!oi Boring � <br /> HE-01434-09 IC#140-0423 6/Osa <br />