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� _ ; _ _ _ _ <br /> wELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„I �H� <br /> County Name <br /> . WELL AND BORING SEALING RECORD Mennle9oNa Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> �epin ��ee�e e�a�k�,�o,k�ow�> _ <br /> Township Name Township No. Range No. Section Na Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> oren� 117 3 Q 3i 3 /� �UG �� RECEIVED <br /> GPS Latitude degrees minutes seconds ` (�[ O � � <br /> LOCATION: Depth Before Sealing /• � , ft. Original Depth��� / V C�. <br /> Longitude degrees__minutes seconds q UIFER(S) STATIC WATER LEVEL /� <br /> Numerical Street Address or Fire Number and City of Weli or Boring Location ingle Aquifer ❑Multiaquifer ���/// y��QF O <br /> 23�8 Rest Pt Crl Vi,V[2V WEL BORING p�Measured ❑ Estimated R�NO <br /> i� <br /> �ater Supp�y Well ❑Monit Well �, � <br /> Show exact location of wetl or boring Sketch map oi well or boring <br /> in section grid with"X" location,showin p�dberty ❑ Env.Bore Hole ❑Other �� tl. �' below ❑above land surface <br /> N (�� lines,roa��uildings. CASING TYPE(S) <br /> 3 <br /> -- - _ -- _ ,�� �teel Plastic ❑Tile ❑Other <br /> W E WELLHEAD COMPLETION <br /> � � <br /> � � � Outside: ❑Well House Inside: ❑Basement Ottset <br /> ' -_-- � , <br /> ---- -�-- --�— , <br /> ' �^'�� �Pitless Adapter/Unit ❑Well Pit <br /> ---- -i-- -i-- --�-- � <br /> S � �'S, � ❑Well Pit ❑Buried <br /> �r,nne—� <br /> ❑Buried <br /> PROP�R�TsYp OWpNER'Sy�NpAME/CsOMPANY NAME CASING(S) <br /> "�`� r�!^'�1� Di m �r/ Depth � � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if diflerent than well location address indicated above <br /> � � �� in.from�_ to ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> i'l�ht CIL, 51�W2 in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown `�_- <br /> s <br /> in.f�Oril t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOL� � <br /> Well owner's mailing address if diflerent than property owner's address indicated above Screen from � t0�ft. Open Hole from f0 ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruct�io�1,} <br /> Type of Obstructions(Describe) �l�✓ti'�/�- / ��f ` * ` U��/� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ NO D2SCfib2 <br /> FORMATION <br /> If not known,indicate estimated formation log irom nearby well or boring PUMP � <br /> . _,,� U l�� Type SU E.% �U�T J <br /> ~J C�emoved ❑ Not Present ❑ Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> LX No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> !� <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 /> ,� / `'� / <br /> Grouting Material f`���� ��/�,i�.�.{�m � to 1J�ft. 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 W SEALING Other unsealed and unused well or boring on property? ❑ Yes �[Vo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minoesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. � � - � � _ <br /> Dort Str�dola We11 Drilling Co,. Inc. 27172 <br /> Contractor Business me . ,.-- _ License or Registration No. <br /> - � <br /> `_�`,;-;.N , = :w.; I..:� -;.:; <br /> A on d epfesentative ignature ' _. Date <br /> H 21 �; , .._ _. �._j,. <br /> LOCAL COPY �r .'r+- _._�'; _/L-,^ i �'�,,}.iY'�,,. <br /> Name of Person Sealing Well or 8oring; � <br /> k... . . � . ._ .. � �. . ... . . <br />