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wE��OR BORING LOCAnON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' ������
<br /> Courlty Name
<br /> WELL AND BORING SEALING RECORD M nnlesoNa Unique Well No.
<br /> Minnesota Statutes,Chapter 1031 or W-series No.
<br /> . ��ea�e a�k n oa k�o�m�
<br /> Township Name n 7 ownship No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed
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<br /> GPS Latitude degrees minutes seconds y ��
<br /> LOCATION: Depth Before Sealing � ft. Original Depth ft.
<br /> Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL
<br /> Numerical Street Address or Fire Number and C'dy ot Well or Borinq Location � Single Aquifer ❑Multiaquifer
<br /> � � WELUBORING �Measured ❑Estimated
<br /> ;,, ,
<br /> Water Supply Well ❑Monit.Well
<br /> Show exact location of weli or bonn-� Sketch map of well or bonng "
<br /> in section gnd with"X" (f location,showing property ❑Ern.Bore Hole ❑Other -x - ft. �]below ❑above land suAace
<br /> lines,roads,and buildings.
<br /> N Y�{ CASINGTYPE(S)
<br /> � � � �
<br /> !
<br /> , � � � a ;,
<br /> �� -T- -�-- -,-- -r- ..-�-----"\ ;:. ... �' ..
<br /> � ' ' �? �]Steel ❑Plastic ❑Tile ❑Other
<br /> 1 I !
<br /> W —�- -;-- - -- -- -- E i=` f WELLHEADCOMPLETION
<br /> , , .
<br /> � � � � . •
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<br /> ,. , � � � � --� Outside: ❑Well House Inside: �Basement Offset
<br /> _Y_ _i__ _l'_ _'�__ ...�..
<br /> l�mb �� � ❑Pitless AdaptedUnit ❑Well Pit
<br /> ' -�- -�-- -�-- --i— I ..-.,
<br /> Z ❑Well Pit ❑Buried
<br /> S
<br /> �—"'"�°—�" ❑Buried
<br /> PROPERTYOWNER'SNAME/C P NAME CASING(S)
<br /> � �€ r.'-� � �j�. Diameter Depth Set in oversize hole? Annular space initially grouted?
<br /> Property owrier's mailing � ss it different than well location address indicated above 4�"�` `�
<br /> . � � in.ffom_;,_ to i;l�..-j ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
<br /> , . 1 �� �'�--�..�
<br /> � j f )- �r� in.f�Om to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
<br /> �+j � . ��� r '�-r:� .sP'�€.,,,.`-r'"if
<br /> i 1 ;_.i.�t in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
<br /> < �., fr
<br /> WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
<br /> ``, >
<br /> Well owner's mailing address if ditterent than property owner's address indicated above Screen from,''� `� ,'?to�ft. Open Hole from t0 ft.
<br /> OBSTRUCTIONS
<br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
<br /> � Type of Obstructions(Describe)
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑ No Describe
<br /> FORMATION
<br /> If not known,indicate estimated tortnation log from nearby well or boring PUMP
<br /> Type
<br /> ❑ Removed � Not Present ❑Other
<br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
<br /> ❑ No Annular Space Ezists ❑ 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 from�to �� R. 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 kfowledge.
<br /> � �. , �: /
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<br /> ',�•�o`.-+,'P �'/��r^ � {.i
<br /> Contractor Business Name License oi Registration No.
<br /> -% ,�f r, � .;�,�.,�... / � '� '� �
<br /> Autlfanzed Representative Signature / f � . Date
<br /> f J
<br /> LOCAL COPV H L� i ��� , ��� , �; �f � ,L ��� l.{
<br /> Name ol Person Sealing Well or Boring
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