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WELL OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I '9 ���� O <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennlego a�Unique Well No. � <br /> Minnesota Statutes,Cha ter 1031 or W-series No. <br /> q P (Leave blank lnolknownl <br /> �'�enn+� in <br /> Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed �, Date Well or Boring Constructed ��� i� <br /> (?COriO 1 7 $ _%_. { �'� �...� � ,�, <br /> p GPS LOCATION- decimal degrees(to four decimal places) �9^ �" ,� `F � � 1 J <br /> ; Depth Before Sealing__ � �/ � ft. Original Depth_.. .__ r`.h.'��' <br /> Latitude_ Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> � Sin le A uifer Mul�ia uifer ��'��"`" " <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �. 9 9 ❑ q . _ � F <br /> ¢ 'G) WELUBORING [�Measured �,.j Estimated D�f�ur�f_i � � ��w+ <br /> 392� Cherr� Ave �r�l�{3 J�JiJ`t �Water-Suppiy Well i;Monit Well <br /> Show exact location of well or boring Sketch map of well or boring -��Env.Bore Hole .��Other � ;P ft. ��below ']above land surface <br /> in section grid wi�h"X" location,showing properry �- <br /> N lines.roads,and buildings. CASWGTYPE(S) <br /> --'--- --i-- ---'-- ---'-- � <br /> �Steel []Plastic (�Tile [�,Other <br /> --'--- -'--- --5---+-- WELLHEAD COMPLETION ''� <br /> . W ; ; ; ; ET _ <br /> . � � � � Outside: ��`:Well House ❑At Grade Inside: � I Basement Offset `� <br /> Y�nn'�ie �Pitless AdaptedUnit �I Buried ;�Weli Pit <br /> -- - - I �Buried <br /> 1 ]Well Pit <br /> S ❑Other <br /> �-i Mile� ❑Other._,._ -- <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � e 1 , Diameter /' Depth Set in oversize hole? Annular space initially grouted? <br /> Properry owner's mailing address if different than well location address indicated above �in.from V t0��t. ❑Yes `�Vo ❑Yes [i NO ❑Unknown <br /> 253 Iake St E <br /> in.from to ft. �Yes '`j No r j Yes ❑No ❑Unknown <br /> tdayzata, '�r1 55391 <br /> in.trom to ft. `Yes ��No ❑Yes [�No []Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> Screen from ���� to / �� ft. Open Hole from ro fl. <br /> Well owner s mailinq address if diHerent than property owner's address indicated above �--- — ---- <br /> OBSTRUCTIONS <br /> '�Rods/Drop Pipe ;...J Check Valve(s) �_�Debris u Fill ;�:No Obstruction <br /> - Type of Obstructions(Descnbe) ,t.�{� ��--�""___ _____. _ <br /> GEOLOGICAL MATERIAL COLOR HARONESS OR FROM TO Obstructions removed? Yes I,_.�No Describe <br /> FORMATION <br /> PUMP ' <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> �.-- <br /> f- <br /> Type._.__. r,,...a �cve-- _ <br /> �;Removed '�Not Present I�Other____ <br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> [�No Annular Space Exists j_;Annular Space Grouted with Tremie Pipe �_J Casing Perioration/Removal <br /> in.from_ to______ __tt. ]Perforated ]Removed . <br /> ___in.from __ _ to____ ft. 'i.]Perforated ]Removed <br /> ,� Type of Perforator `' <br /> VARIANCE <br /> Was a variance granted from the MDH for Ihis well? ';�Yes �No TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag ot bentonite=50 Ibs.) <br /> Grouting Material � ` -7 r�-°.��-� from ���.�__ to.__{��! �ft. _ yards__L (�. bags <br /> from to ft. _ yards, bags <br /> __ from to�� ft. yards______ bags <br /> OTHER WELLS AND BORINGS . <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES W SEALING Other unsealed and unused well or boring on property? ❑Yes i 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 ot my knowledge. � <br />� <br /> Don Stcxlola i�ell Drillin� Ca�_ Inc._ 1691 � <br /> —---. --- - ---- - --_ – <br /> Licensee Busi�Name - y License or Registration No. r <br /> . � Y <br /> - . -, . ���..� � �41J'i> � <br /> . ,�;t � - ..---. .__. __.. <br /> e i/1 f7epresentative Signatuie `� � Certilied Rep.No. Date <br /> H 3 2 9 410 Ti� �e��r — <br /> LOCAL COPY Name of Person Sealing Well or Boring <br /> HE-01434-14 IC#140-0423 5n3A � <br />