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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �4 3 0 <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. <br /> Minnesota Statutes,Chapter f03I or W-series No. <br /> (Leave blank i�nol known) �4 <br /> Township Name Township No. Range No. Section No. Fraction(sm.�IgJ Date Sealed Date Well or Boring Constructed � <br /> '' '' � ;F/� Url <br /> *� . <br /> GPS Latitude degrees minutes ___ seconds Depth Before Sealing G.�� ft Original Depth ft. � <br /> LOCATION� Longitude_ degrees _ minutes___ seconds A�UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location � ingle Aquifer ❑Multiaquifer t.Rrn� ��� '-. <br /> /�,. �. <br /> 145U BcseketC� PbinE Itd, VL� WELL/BORING [�vleasured ❑Estimated Date Measured� <br /> Water-Supply Well ❑Monit Well � <br /> Show exact location of well or boring Sketch map of well or boring �- �/'� <br /> in section grid with"X:' location,showing properry ��Env.Bore Hole ❑Other �_R �below I�_j above land suAace <br /> N � lines,roads,and buildings. CASINGTYPE(S) <br /> > --'--- -'--- ---`-- ---'- ' <br /> _ .a Steel , 1 Plastic U Tile ❑Other _ _ <br /> �� --'"" `�------`-- ---'-- WELLHEAD COMPLETION �� <br /> W ; ; ; : ET _ _ <br /> ' ' ' � ' J�.�� Outside:�Well House I j At Grade Inside: '�� ��.Basement Offset �J <br /> '. --�--- --�-----�-- --.-- "'� w � <br /> 'h nniie\ r]Pitless AdaptedUnit �_i Buried _�Well Pit � <br /> a <br /> ���! --�----�----%- --�- ,;�Buried <br /> S '_]Well Pit � <br /> �—1 Mile� 1 �]Other ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) � <br /> Diameter � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owners mailing address if different than well location address indicated above �� <br /> �i'�in.from_�_ to_���t. �J Yes �No ❑Yes �]No I���.Unknown <br /> �7� t'Yir""'t J11 ��� `iYJ in.from to ft. ❑Yes [�No �Yes ❑No i,_Unknown <br /> Minneapolf s, I�►1 55495 <br /> in,from to ft. ❑Yes []No �J Yes ❑No =Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> � / <br /> Well owner's mailing address if diHerent than property owner's address indicated above SCreen from to fl. Open Hole from__��_�to��`ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑Check Valve(s) [�Debris �Fill ❑No Obstruction <br /> Type of Obstructions(Describe����G :� ��� 4- /�i M!7 <br /> GEOLOGICAL MATERIAL COLOii HARDNESS OR FROM TO Obstructions removed? es ❑No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> �' . .TYpe �Ub—�E.��r' ; <br /> ' �� '�''"'��-'����•} (� �`�" `� Removed ���.'Not Pr�ent ❑Other - <br /> ?,� � � �`�� ,� , METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �o Annular Space Exists ;` �Annular Space Grouted with Tremie Pipe I,J Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated [J Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MA7ERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> �- � r <br /> Grouting Material�/�/ �/�/��LJ/From� to��ft. yards��bags <br /> from to tt. 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? (J Yes o How many? <br /> " UCENSED 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 /> i <br /> � DOYI SCO(�OY.B �ZZ �?L'�.lliII� CO.�_it1C- �4� <br /> Licensee Business N e - � License or Regishation No. <br /> , :�; ,,1 G 7 <br /> ertif d epresentative Signa re ` Certilied Rep.No. Date <br /> f <br /> ��` � <br /> !';C;F,J_COPY H _ �'',_.. /,�,� raY.."LL..j'�✓�..-� <br /> 2 fi 4 3 0 5 Name ol Person Sealing Well or Boring r <br /> HE-01434-10 IC#140-0423 � 5/o�a <br />