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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring "�j � " � ': WELL OF BORING LOCATION Sealing No. H .? �.,� e.�r � i3 � : �o�n,Y Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes, Cha ter 1031 oz W-series No. P a Olank il not known '�eru� ia �� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Construded VLa� GPS LOCATION- decimal degrees(to four decimal places) � - Depth Before Sealing ��___fl. Original Depth ft. Latitude______ Longitude_ _ AOUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location .Single Aquifer � �Multiaquifer ,1 559 F�,ck Lene �rQ� WELUBORING .�Measured I i Estimated Date Measured �!1/� �� Water-Supply Well [';Monit.Well � Show exact location of well or boring Sketch map of well or b ring ��Env.Bore Hole �Other _ �� ft. i�below r�above land surface in section grid with"X:' location,showing prope y - lines,roads,and buildin s. N J CASINGTYPE(S) ' ..L-- --'--- ---`-- ---t- w_ I I t i th ,'+. .] � � j ; � � � tee , as ic ( '�,Ti e �0 er . S L�P - — � '--- -' `' `-- ° � WELLHEAD COMPLETION W E � � �i __ _ __ T o� Outside: ._I Well House ��,_,At Grade Inside: �.J Basement Offse�� r g Z��5 'h M��ie �� _'Pitless Adapter/Unit �Buried �.]Well Pit 1 � _ �j Buried S nt� a� � ,_.Well Pit " ^IT/ np^� � � � ; J' _ �J Other V 1 I \_[CW Q �1 Mile—� I._Other_._______ ______ a PROPERTY OWNEF'S NAME/COMPANY NAME CASING(S) JQ� Q� Diameter � Depth � Set in oversize hole� Annular space initially qrouted? Prope«y owner's mailing address it different than well location address indicated above �� in.from to ft. I�,�Yes �No i Yes �L_I NO ❑UnknoWn -_�- _._�_ �. - .- P��• LRI�i 63� in.from_ to fL �]Yes [ j No [�Yes ��No ❑Unknown : Osseo, t�t►T 55369 : in.from_ to_..____ft. `�Yes , ;No ;.�Yes L.�i No ❑Unknown �-� WELL OWNER'S NAME,�COMPANY NAME SCREEWOPEN HOLE / / � � Well owner's mailing adoress if different than properry owners address indicated above SCfeen from�_ to�. ft. Open Hole from to ft ` OBSTRUCTIONS �l,RodslDrop Pipe ��-.Check Valve(s) (�Debris �]Fill '.]No Obstruction �.. Type of Obstructions(Describe)__ C_t��(�" ��Q��__.__ . �� GEOLOGICAL MATERIAL COLOR HARDNESS Oii FROM TO Obstructions removed? Yes � �No Describe--J��_/�^► FORMATION - PUMP If not known,indir,ate estimated formation log from nearby well or boring. Type ; i-''Removed '��✓Not Present i ,Other__, _ , a i� .. . .-__.__.-- - ---- - METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists . _Annular Space Grouted with Tremie Pipe i, 'Casing PerforatioNRemoval 3 — , in.from_._ to___ _. fc '� �Perforated __�Removed ; ___._. ___ in.trom _to__ _ tt. ',J Perforated IJ Removed Type of Perforaror VARIANCE ;' Was a variance granted from the MDH for this well? '�N ° ..,Yes o TN#_--.------ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) -. Grouting Material��,(,j� trom_�___ to��_�ft. _ yards � bags . _ . _ ._ from to ft. _ yardg _ _ _ bags _ _ _ from _ to _ ft. _ yards_____ bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DA7A,DIFfICULTIES W SEALING Other unsealed and unused well or boring on property? �, .Yes o How many? � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION " This well or boring was sealed in accordance with Minnesota Rules.Chapter 4725.The information contained in this report is Vue?o the best of my knowledge. �� t+Git-� 2��-t�� .� -- iL censee usin�e "�•`Ca �1� �• �cense or Regishation No. ,�': 8-12—I5 r � -- _ _- _ _ __ — _ _ Ce � p . ��r%at SignatuPe CertiliedRep.No. �Date ., " 3 3 310 9 J� :�c�on :� LOCAL COPY -- - - — --- - - - - - - _ - - -- - -- Name of Person Sealing Well or Boring \� HE-01434-14 IC#140-0423 9�3a