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� MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring „$ "� +Ff'# �' � �
<br /> WELL OR BORING LOCATION Sealing No. H .� ,.!., ��,.� �
<br /> ��� County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
<br /> Minnesota Statutes, Chapter 1031 0�W-series No.
<br /> Ii�nr��,in
<br /> Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed
<br /> �ror�o 117 ?3 20 �� 9W �s? Z-12-14
<br /> GPS LOCATION- decimal degrees(to four decimal places)
<br /> Depth Before Sealing_ �___ ft. Original Depth ft.
<br /> Latitude __ Longitude
<br /> AQUIFER(S) STATIC WATER LEVEL
<br /> ��� Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Multiaquifer
<br /> t WELUBORING .r�vleasured ❑Estimated Date Measured ��12��
<br /> 3225 CascopC'rl, �rono �
<br /> ; I,�'�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 __ _� -i ft [�below �.�]above land surface
<br /> lines,roads,and buildings.
<br /> nl } CASING TYPE(S)
<br /> �T ?'-
<br /> .: _'___ ' ` __'_ �
<br /> � i i i i I�s�eei f�Piast�c L]T�ie [�ome� '
<br /> :' --�--- --�------�-----`-- ELLHEAD COMPLETION
<br /> : W ; ; : � ET � "" -
<br /> ,
<br /> ,
<br /> , . . ; �".' `� �
<br /> . , 1 r r f M�i } Outside: i _I At Grade Inside: �Basement Offset
<br /> _ ___ __ ___ __ __ __ __ � _,Well House �
<br /> �' --'--- --1------;-- ---'-- ,_, itless A p dUnit ... uned Buriledit
<br /> � P da te B �J
<br /> � ❑Well Pit f�
<br /> S
<br /> Other
<br /> �� — —
<br /> �i Mile� ❑Other_
<br /> PROP Y2 OWNER'SaN.A,ME/COMPANY NAME CASING(S)
<br /> ���i'�� �+ >��nS Dia(�qeter n Depthy.G Set in oversize hole? Annular space initially grouted?
<br /> Property owner's mailing address if different ihan well location address indicated above G E f �V
<br /> __. in.from to ft �'Yes �No ❑Yes ❑No (J Unknown
<br /> �1��1� Ct� a[.� � in.from to ft. '�,�j Yes '�J No ❑Yes ❑No ❑Unknown -
<br /> tio�kins, 1�N 55343 --
<br /> _in.from to ft. I---�Yes �:No ❑Yes ❑No � �]Unknown
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE '
<br /> Well owner's mailing address if different than property owner's address indicated above, Screen from _�" __to `"" _ft. Open Hole from to ft.
<br /> OBSTRUCTIONS
<br /> }�Rods/Drop Pipe �. I Check Valve(s) [_J Debris ❑Fill ❑No Obstruction
<br /> Type of Obstructions(Describe) ur�`L} ��� � C}�Lj.?1C�eL _____
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �Yes ❑No Describe
<br /> FORMATION
<br /> PUMP
<br /> If not known,indicate estimated formation log from nearby well or boring. 7��,
<br /> Type�t L�.+�
<br /> .j I y�`Removed ❑Not Present [�1 Other �
<br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
<br /> �No Annular Space Exisis I]Annular Space Grouted with Tremie Pipe [.;Casing Perforation/Removal
<br /> ' . .___in.from to ft. ❑Perforated '�]Removed "
<br /> : in.from___ _____ to ft L�Pertorated i ]Removed �'�
<br /> = Type of Perforator -
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? [!Yes �'No TN#
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> Grouting Material�at �.'�,('�� Q from�.__ to___{S� 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 IN SEALING Other unsealed and unused well or boring on property? ❑Yes [�No How many?
<br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
<br /> This weil 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 /> non Stoc�vl� �+�ell nrillin; Co,. Inc. lf��?1
<br /> Licensee Business ame . '� License or Regist�ation No.
<br /> � -:;�" ��"�_ Z—I�—IG
<br /> � _— % - ,
<br /> , ,.:. .aM .
<br /> , �— __ _— -- - ;
<br /> �� e 'd Representative Signatur Certilied Rep.No. Date
<br /> ` LOCAL COPY H �j TiR1 SC�CLIPC
<br /> �;�(„3��o Name of Person Sealing Well or Boring
<br /> �; HE-01434-14 IC#140-0423 5��3q
<br /> ,
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