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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Borin �7 �� "
<br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. 9 H ��'�� �� �- _
<br /> County Name Minnesota Unique Well No.
<br /> Minnesota Statutes, Chapter f037 or W-series No.
<br /> `�ez�r�e�jn �e�e e�z�k„�o,k�ow�,
<br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed "
<br /> �Cc�no 11? 23 2Q �F'�fi�;�,...,� U Sr=� I�-�
<br /> GPS LOCATION– decimal degrees(to four decimai places) /�' �
<br />" � Depth 8etae Sealing f,i/_ ft. Original Depth,__..,_. ft. .V,
<br /> atitu e________ ongitude
<br /> -- —
<br /> �� �� UIFER(S) STATIC WATER LEVEL '
<br /> /j� m rica�et Address or Fire Number and City of Well or Boring Location ,'Single Aquifer �]Multiaquifer � � �,r�
<br /> U ?Jt; rr�g0 40e� �r�� WF�UBORING Measured ;.j Estimated DateMeasured __�1��� r.�'"1Y
<br /> j� pp y Manit.Well (�i� � �/
<br /> Show exact location of well or boring ..� �� Sketch map of well or boring � Env.Bore Hole i_� �` ^� x�
<br /> ater- u I Well ,_.
<br /> in section grid with"X" location,showing pr erty - ..I Other_ ,__ __ ____ ._ ft. �IV below ...;above land surface �.
<br /> , nes sq�{is,and bu mgs.
<br /> N - -- �-__-� �_..�..,,-�. CASINGTYPE(S)
<br /> '� '--- � L .--
<br /> , , � 1� [�teel , �Plastic , I Tile '�...i Other_..._-- — --_. _._.---- .`
<br /> ` ''--- ` �-- •�� WELLHEAD COMPLETION � � �
<br /> .. � � � � ...__„
<br /> . W ; ; ; : ET
<br /> �` __;___ __,___ __�_ __�__ Outside: _.'�,Well House ��At Grade Inside: �Basement Offset �
<br /> � ' ' ' ' t - d � eil Pd
<br /> , , , , '/M'e LI Pitless AdaptedUnit � une .__
<br /> �
<br /> : I._,g . 'W �:
<br /> --,--- --,-- --�-- --:- l --.,..__.__..�
<br /> ���Buried
<br /> S ❑Well Pit
<br /> F-1 Mile� ❑Other �..�Other _ _
<br /> PR(Q�PEp7 TY OWNE(g�'S NAME'CO NY NAME CASING(S)
<br /> `-�O1�Q� `�U-S�� ��g Diameter � � Depth f Set in oversize hole? Annular space initially grouted?
<br /> Properry owner's mailing address if different than well location address indicated above � �p �j -
<br /> �,�in.from to�� / ft. [j Yes �No ❑Yes ❑No ❑Unknown
<br /> 216 [��ter �t
<br /> ��l.g.l��r� i�3 55331 in.from_ to ft. ���Yes �_.No [�Yes []No ❑Unknown
<br /> j _in.from _ to _ft. n�Na � ��-
<br /> ❑Yes �,,, ;J Yes ❑No '�,Unknown
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
<br /> r �
<br /> Well owner's mailing address if differem ihan property owners address indicated above Screen from t G. / t0__���___ft. Open Hole from_ to ft.
<br /> t
<br /> � OBSTRUCTIONS
<br /> I �Rods/Drop Pipe �_I Check Vaive(s) _,'Debris �]Fill �No Obstruction
<br /> ' Type of Obstructions(Describe)_.,,.___
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obshuctions removed? ❑Yes �._No Describe -
<br /> FORMATION
<br /> PUMP
<br /> If not known,indicate estimated formation log from nearby well or boring.
<br /> dCl L C Q �3 TYPe ---. __-- -
<br /> , � '�Removed �Not Present ❑Other �-
<br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,Ofl CASING AND BORE HOLE:
<br /> j�No Annular Space Exists '.�-'Annular Space Grouted with Tremie Pipe �]Casing Perforation/Removal
<br /> �i in.from,,.._ to ft. I.�,]Perforated ` ��Removed
<br /> in.from, to _ _ft ���]Perforated [ J Removed
<br /> Type of Perforator______
<br /> VARIANCE
<br /> Was a variance granted from ihe MDH for this well? [_]Yes No TN#
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> ; ' �� , r
<br /> �� Grouting Material N`/7� ���'vI irom_ to �� ft.__.__ yards � bags
<br /> ' from to ft. yards bags ?
<br /> a __________ from____ to _. , ft. __ _ yards______ bags
<br /> � OTHER WELLS AND BORINGS
<br /> 1
<br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? `�i Yes f�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 knawledge.
<br /> �ln � Y t GQ
<br /> �censee usines––s 10`e - � � � *{,�� License or Registration No.
<br /> , ,,1� �" '`� Ff� ', �'��"14 4
<br /> __-
<br /> _ - __ - ---- - — .
<br /> Certified Represent 've Signatur� Certilied Rep.No. Date
<br /> Jim Antonson
<br /> ' LOCAL COPY H 3 2 4 7�4
<br /> - -- --. _------
<br /> Name ol Person Sealing Well or Boring
<br /> HE-01434-14 IC#740-0423 Sn3R
<br /> ��.. .. . . .._ . . _
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