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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„I �C��Q� <br /> Counry Name <br /> WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. v " <br /> Minnesota Statutes,Cha ter 103I or W-series No. <br /> P (Leave blank i(no�knownJ <br /> Township Na e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Q '' l� tJU�,/� ��'7 <br /> � <br /> GPS Latitude_ degrees minutes._ seconds Depth Before Sealing ��!� ft. Original Depth_ ft. <br /> LOCATION: Longitude degrees_ minutes_ _ seconds �UIFER(S) STATIC WATER LEVEL <br /> Nuqm.e�r�ical Street Add�re1s.s,.or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ]� ...,�� A f� <br /> &JQ� N• �nJV� ��• ��� 55391 �✓ LUBORING �'J'Measured ❑Estimated DateMeasured - �� <br /> �Water-Supply Well ❑MoniL Well �}� `L <br /> Show exact location of well or boring Skeich map of weil or boring �J Env.Bore Hole ❑Other �`-� ft.1f�.�,below ❑above land surface <br /> in section grid with"X" location,showing property � — � <br /> lines,roa s,and bui ngs. <br /> N � CASING TYPE(S) ' <br /> f �,� <br /> "_'_"_ '_i___ ___`'_ ___'__ <br /> - �Steel r,Plastic ��;�Tile ❑Other ___,.__ _ ___ <br /> � --�'--"'-----'`" "'1-' WELLHEAD COMPLETION � <br /> ; W ; : ; : ET - <br /> r • h Miie Outside: ��P ell House !L_J At Grade Inside: �Basement Offset <br /> �—"`""�"'r, ,�, tless Adapter/Unit Buried !�Well Pit <br /> -- - -- 1 �'' <br /> ]Buried <br /> S ❑Weli Pit <br /> ❑Other <br /> f--1 Mile� ❑Othef <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � Diaiaet�y � Dept^ f Set in overs�iz/e hole? Annular space initially grouted? <br /> Properry owne mailing address if different than well location address indicated above � � to ����it ❑Yes '�lo �_ .Yes '�No ❑Unknown <br /> in.from <br /> 1I402 Co�mty Road 3 in.from to ft. ��Yes ❑No [�Yes ❑No ❑Unknown <br /> Hopkins, I�d 55343 <br /> in.from __ to ft ❑Yes ❑No �=�Yes �]No �,�Unknown <br /> '� WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> ��/� t <br /> � Wel1 owner's mailing address if different than property owrer's address indicatetl above Screen from__. ����to•�t. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction� . �a <br /> .� ' f� �/ � � ; <br /> TypeofObstructions(Describe) � /�/V ..-�� !'_�6�'__4' [.[/�7�� <br /> � <br /> 4 GEOLOGICAL MATERIAL COLOR HFORMATIONR FROM TO Obstructions removed? �Yes ; '��No Describe__ _ <br /> PUMP /1 <br /> If not known,indicate estimated formation log from nearby well or boring. Type ���` �,/��{� <br /> ' . � ' i <br /> � 1`-� v � 7��Removed ❑Not Present ']Other_ � <br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,QR CASING AND BORE HOLE: <br /> No Annular Space Ezists ❑Annular Space Grouted wi[h Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to _ ft. ❑Perforated ❑Removed <br /> _._._ in.from .__to__ _ ft. ❑Perforated ❑Removed <br /> i <br /> Type of Perforator__ _ __ __ _ ____ <br /> ❑Other _______ __ . <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> n r � <br /> - Grouting Material���T C'����'U'irom_ �`''�" to �_ZCsft. yards < • bags <br /> from_ _ ro 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? r'��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 <br /> is true to the best of my knowledge. <br /> Dan Staiol.a Well Dcilling Co,, I�. 1691 <br /> Contractor Busin s Name � � License or Regrsfration No. <br /> _ " .�'- 1�r. c7 <br /> Certifi epresentative Signature� - Certilied Rep.No. Date <br /> H �+�.► ���''�''Q-*�°�'`--j <br /> LOCAL COPY 2 616 8 2 *l <br /> Name of Person Sealing Well or Boring <br /> HE-01434-09 IC#140-0423 ..` s/oeR <br />