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wE�L OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' ��� <br /> Counry Name <br /> WELL AND BORING SEALING RECORD M nn'esoNa Unique Well No. <br /> � Minnesota Statutes,Chapter f031 or W-series No. <br /> (Leeva Dlenk il iwl krwwn) <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> ' �rono 117 23 20 2�—C1�32 �,. <br /> GPS ���de de9rees minutes seconds L! <br /> , <br /> LOCATION: Depth Before Sealing Q� 1 ft. Original Depth ft. <br /> LongRude degrees minutes seconds ppUIFER(S) STATIC WATER LEVE� <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aqu'rfer ❑Multiaqu'rfer <br /> _ E�UBORING �Measured ❑Estimated <br /> ��r <br /> y9,Water Supply Well ❑Monit.Well f� t <br /> Show exact location ot well or ring Sketch map of well or boring }{ <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other ��✓ ft. �below ❑above land surface <br /> N � \ lines,roads,and buildings. SING TYPE S <br /> 4 ? <br /> , .�.,-•.r_•, ,:�_�{ ..g.1 4!! ( ) r <br /> _T' _ _ _ __ _l__ 1 <br /> �..f � + �Steel ❑Plastic ❑Tile ❑Other <br /> /� _,.....f <br />. � W -- - -i-- -i-- -- -- E WELLHEAD COMPLETION <br /> � � � Outside: ❑Well House Inside: ❑Basement Oftset <br /> -;r- ---- -;-- -�-- e <br /> ' ��° ��t4�� '�Pitless AdaptedUnit ❑Well Pit <br /> --�- -�-- -i-- --�-- � s� <br /> ❑Well Pit ❑Buried <br /> S <br /> �—�nM°—� ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANYp N.A�,MtE ���+ CASING(S) <br /> � i�1s,i�d L�,�ii Diameter � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address A diHerent than well location address indicated above '�I� <br /> �„�, in.f�Om � to�ft. ❑Yes �o ❑Yes ❑No ❑Unknown <br /> 74(17 �a5tZ8Ca Bl�ci <br /> StT��¢� �rA� � S J�FZ� in.frOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> u�u.ia <br /> in.from t0 ft. ❑Yes �Na ❑Yes ❑No ❑Unknown <br /> � iJ;; i L � . 1`{ .�= � :';r <br /> � WELLOWNER'S NAME/COMPANY AME SCREEWOPEN HOLE <br /> 1 � <br /> Well owner's mailing address if diHerent than properry owner's address indicated above Screen from�t0�ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction ' <br /> �j '"_ ..��- <br /> Type of Obstructions(Describe)-��l/111G�/� /'-L�F � s,,��. � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ NO Desc�ibe <br /> FORMATION <br /> If not known,indicate estimated fortnation log trom nearby well or boring PUMP <br /> �r�.�� :J �1� TYPe <br /> ❑ Removed Not Present ❑Other <br /> >� <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 PerforatioNRemoval <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 /> / � tt <br /> i <br /> 0 3 20 6 Grouting Material /�✓� � � �//.' %'fi—�+m to�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 is <br /> true to the best of my knowledge. <br /> Tbri �tc�dola Well i)rillir�; Col. Snc. 1691. <br /> Contractor Business me � License or Registration No. <br /> :� �%'�..,! �',CJ <br /> x o epresen ative Signa e Date <br /> LOCALCOpY <br /> H 25272� �;: -�- __:,� <br /> Name of Person Sealing Well or Bonng ; <br /> �,. .. . . ,... . _:..._„.... .. . . . .. . . _ ...... . .. . i. � <br />