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Latitude Longitude <br />AQUIFERS) STATIC WATER LEVEL <br />Numerical Street Address or Fire Number and City of Well or Boring Location � Single Aquifer ❑ Multiaquifer <br />�' +*� . �. � � � WELL/BORING � Measured Date Measured % � , `.) ] Estimated <br />Water -Supply WeII ❑Env. Well iA <br />Show exact location of well or boring Sketch map of well or borin <br />in section grid with "X ° location, showing property ❑Temp. Boring ❑Other ft. � below ❑above land surface <br />N lines, roads, and buildings. � CASING TYPES) <br />W <br />�I <br />'�. <br />E <br />T <br />'h Mite <br />l <br />s <br />'--t Mile <br />For temporary borings, provide additional location <br />information, a site sketch, and geology on a separate page. ` <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />"� ] � [� Steel ❑Plastic ❑Tile ❑ <br />WELLHEAD COMPLETION <br />�' <br />Outside: ® Pitless Adapter/Unit <br />'' <br />❑WeII Pit <br />❑Other <br />t,.! <br />Property owner's mga+ili�ng ad{d�ressyif different than well location address indicated above <br />J # i,F 2 <br />€i�.f .. ' <br />•�� �:rr •u•:� �:u <br />property <br />GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM <br />FORMATION <br />If not known, indicate estimated formation log from nearby well or boring. <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />❑ At Grade Instde: ❑Basement Offset <br />❑ Buried ❑Well House <br />❑ Well Pit <br />❑ Buried <br />❑ Other <br />CASINGS) <br />Diameter Depth <br />in. from � to ft. <br />in. from to ft. <br />in. from to ft. <br />SCREEWOPEN HOLtE <br />Screen from `'� to � ` ft. <br />,,O��BttSTRUCTIONS <br />I�RodslDrop Pipe ❑Check Valves) <br />Set in oversize hole? Annular space initially grouted? <br />❑ Yes ❑ No ❑Yes ❑ No � Unknown <br />❑ Yes ❑ No ❑Yes ❑ No ❑Unknown <br />❑ Yes ❑ No ❑Yes ❑ No ❑Unknown <br />Open Hole <br />from <br />to ft. <br />❑ Debris <br />❑Fill <br />❑ <br />No Obstruction <br />Type of Obstructions (Describe) <br />Obstructions removed? � Yes ❑ No Describe <br />PUMP <br />TO ❑Not Present � Present, Remov�erd Prior io Sealing ❑Other <br />Type �i�s, <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 Pertorator <br />VARIANCE <br />Was a variance granted from the MDH far this well? ❑Yes � No TN# <br />GROUTING MATERIALS) <br />Grouting Material -rr� �,�'�.,�Trom�, to ft. yards bags <br />from to ft. yards bags <br />from to ft. yards bags <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 />Licensee Business Name <br />License or Registration No. <br />1�/ <br />