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, �*� .. r `�?� .�� <br /> wELL oR BORING�OCnnON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �!� C O�� <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. G J <br /> � in Minnesota Statutes,Chapte�1031 or W-series No. <br /> t��d�x n�a www�� <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Construded <br /> ' 4rcmo Z18 23 35 3-�OQ2,3 �,. �� <br /> GPS Lalitude degrees minutes seconds �/�/''� � �� � <br /> LOCATION: Depth Before Sealing .—�� ft. Original Depth s ft. <br /> Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL <br /> Numericai Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> ELUBORING �Measured ❑Estimated <br /> � Water Supply Well ❑MonR.Well � <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section gnd with"X" ._��G � location,showing property ❑Env.Bore Hole ❑Other �ft. �below ❑above laixl surface <br /> i� lines,roads,and buildings. <br /> J'"• <br /> N �� CASING TYPE(S) <br /> - - - - - -- -i— "'� <br /> Steel ❑Plastic ❑Tile ❑Other <br /> �� W -�- -i— -i-- --i-- E '�,, f�,_,.,,_� WELLHEAD COMPLETION ( <br /> � , � � s <br /> : � � � � ' ( Outside: ❑Well House Inside: ❑Basement Offset � <br /> -r- -�-- -r- -i— � � � <br /> �^� ` • �Pitless AdaptedUnit ❑Well Pit <br /> —�- -�-- -�-- -�-- '.'� <br /> I �' <br /> 1�'�,��}�ti�. �� ❑Well Pit ❑Buried <br /> S <br /> f'---'�� . �, <br /> ❑Buried <br /> PROPERTV OWNER'S NAME/COMPANY NAME CASING(S) <br /> �� �r���� Dia telr Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address rf dilferent Man well location address indicated above /! /'� <br /> � in.frorilS� to,�ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> 2U00 A�eB Dr <br /> �,.,,�.�t 1��' � � in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unkriown <br /> 17lf[.t W\f l l <br /> in.f�om to ft. ❑Yes �No ❑Yes ❑No ❑Unknawn <br /> � WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE " <br /> Well owner's mailing address if different than property ownets address indicated above Screen from t0 ft. Open Hole from�[_t0�� <br /> 7���.����� <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> i Type of Obstructions(Describel ��,,�,rj�� 1/T�C_� !� i� <br /> �e7 �:.- —�-_� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ NO DeSCfibe � <br /> FORMATION ( <br /> If not known,indicate es6mated fortnafion log from nearby well or boring PUMP �E <br /> Type <br /> ,F,..,.�.� O�� Y`'�� . <br /> �Removed ❑ Not Pres nt ❑Other <br /> -����` ':.,,.h°�'�-��— � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> i No Annular Space Exists ❑ 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 /> �° I <br /> Grouting Materia�f(1�,�, �ff� `���from_�ro��tt. yards �� bags <br /> ! from to ft. yards bags <br /> � from to R. yards bags <br /> ? OTHER WELLS AND BORINGS - <br /> � <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 /> Scodola Well Dril co. Inc. 27172 <br /> Contractor Bu e Name License or Registr.�3tion No. <br /> __ �-- _:✓�.� �/ D� <br /> o d r se' rve �gn�tuA2 Date <br /> LOCAL COPY H Z Z V'J V Z .. �,-,,._. d._i f .,/�3't ,.��1�1.�.. <br /> Name ol Person Sealing Well or Bonng <br />