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WELL OR BORING LOCA71oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �2 7 3 3� <br /> M WELL AND BORING SEALING RECORD Sealing No. <br /> Counry ame Minnesota Unique Well No. <br /> -% �;,/% Minnesota Statutes,Chapter 10.?I or W-series No. <br /> ,�_��� ���o�k n�a�,o�,�� <br /> Tqvr�ship Name wnship No. Range No. Section No. F -i ly� Date Sealed Date Well or Boring Constructed <br /> � J , r <br /> ,�,�.�: �� I� � .,. ....,. .,. , � ����� y ,<, ,��, � <br /> GPS Latitude degrees minutes seconds ,^} � � � <br /> IOCATION: Depth Before Sealing �� � � tt. Original Depth R. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Loca�ion �`]Single Aquifer ❑MulUaquifer <br /> ,-- ;J� � WELLBORING �'Measured ❑Estimated <br /> f� r � �.. Water Supply Well ❑Monit.Well <br /> Show exac location of w I r tch map of we or boring <br /> in section gnd with"X" zS ocation,showing property ❑Env.Bore Hole ❑Other �ft. �below ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> ; � � � � <br /> ,. --r- -T- -�-- -�-- ---_ . . <br /> . . . ...._ ... - � <br /> � �]steel ❑Plastic ❑Tiie ❑Other <br /> � , � ?i _ <br /> W -�- '-- -;-- --i-- E ' �r„�g.q..�--�^ WELLHEAD COMPLETION <br /> � � � � � � utside ❑Well House Inside: ❑Basement Offset <br /> � O <br /> —�- -;-- -r- --�-- ' .. � <br /> _.�! `C�/_-'-�- <br /> �^� �. � � �Pitless AdapteAUnit ❑Well Pit <br /> --`- -i-- -i-- --�-- � ! J, <br /> `-"�� r' ❑Well Pit ❑Buried <br /> S ��-�"""—�' ❑Buried <br /> ` l <br /> PROPF�RT�OWNER'S N�jME/COMPANY NAME s' ', CASING(S) <br /> tJ % <br /> �{`:- Diameter DepV� Set in oversize hole? Annular space initially grouted? <br /> Pia ownePs maif� �address 1F�' tio ad indicat <br /> � I�.from��*'to�ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> �r <br /> i ;_j : � � �' �` � �1 r� ❑ ❑ ❑ ❑Unknown <br /> � � � l� - ���"��� / �=�-- in.from to ft. ❑Yes No Yes No <br /> S.�' -. <br /> �� i� .�j�� . /�. . � � t� ��� '`4, in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> .�(,�%d.�C 1 <br /> WELL OWNER'S NAMEICOMPANY NAME SCREEWOPEN HOLE <br /> � <br /> Well owner's mailing address it different than property owners address indicated above Screen from�t0��� Open Hole from t0 ft. <br /> i <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? ❑Y2S ❑ NO DBSCfib@ <br /> FORMATION <br /> If not known,indicate estlmated formatlon log from nearby well or boring PUMP � <br /> Type ��y,�b'/' <br /> p,Removed ❑ Not Present ❑Other <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 Perloration/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 Matenal f �, , �!'.� ` ' to �, ft. yards f� bags <br /> from to ft. yards bags <br /> from to tt. 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 kno�yvledge. <br /> i / <br /> � � .��` n. t / �n/ 'lrf l Y .,. •�� ! f .. <br /> CaiVactor$us s . �nae or ist bon No. <br /> 'I�- - ,.? f� ''�`�'�� <br /> Aut ni . nafure�'- . -• � Date <br /> >' <br /> H 22733� � <br /> LOCALCOPY � � <br /> Name ol Perso��'' 'g e or ng <br />