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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 31 <br /> Counry Name <br /> WELL AND BORING SEALING RECORD Minne oNa Unique Well No. <br /> Minnesota Statutes,Chapter 103/ or W-series No. <br /> (Leeve blenk X M Ivqwn) <br /> ?' Town ip a Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Construded '1 i�� <br /> V <br /> �i� v. v. I � � <br /> f <br /> y GPS ��� degrees minutes seconds -(1 � � �oDS <br /> LOCATION: Depth Before Sealing_?b ft. Original Depth <br /> Longftude degrees minutes seconds pQUIFER(S) STATIC WATER LEVEL op <br /> Numerical Street Address or Fire Number and City oi Well or Boring Location Single Aquifer ❑Multiaquifer ��oN� <br /> 25�5 Narth Shoce 1� OtOtiO ELUBORING YYMeasured ❑Estimated <br /> �ater Supply Well ❑Monit.Well J`" / / <br /> Slww exact location of well or boring Sketch map of well or boring !�,/f'} <br /> in section grid wi[h"X" location,sho ' property ❑Env.Bore Hole ❑Other �ft. �below ❑above land suAace <br /> I' s,roads,a�d ildings. <br /> N , �.:,., ;; � CASING TYPE(S) <br /> - - - - - -- -i-- <br /> Steel ❑Plastic ❑Tile ❑Other <br /> �' <br /> W —�- -i-- -;-- --;-- E `:y. � WELLHEAD COMPLE110N <br /> � , � �J <br /> � � � Outside: ❑Well House Inside: ❑Basement Oftset <br /> � <br /> ; -'r- -�-- -f- --�— ° �/ <br /> � �mib � p�Pitless AdaptedUnit ❑Well Pit <br /> --�- /� <br /> -�- -�-- --�-- � <br /> ❑Well Pit ❑Buried <br /> S <br /> �--""'"� ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diamet�rt Depth l Set in oversize hole? Annular space initlally grouted? <br /> ; Prope er s ailing ad re s ifferent than well loca dr s n ica /� <br /> � in.ffom `�'� t0��ft. ❑Yes bhJo ❑Yes ❑No ❑Unknown <br /> BC8tj .TOt2�8 �\ <br /> J� ��ld Jt J+ Ste 42(X) in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown - <br /> ���8t^��1g! S-�` +�4� in.from t0 ft. ❑Yes ❑Na ❑Yes ❑No ❑Unknown <br /> i WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � f <br /> � Weli owner's mailing address'rf diHerent than property owner's address indicated above Screen from_�t0�ft. Open Hole from t0 ft. <br /> � OBSTRUCTIONS <br /> �[Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe)�,fS(/S�.f�/"� ��� � ��I��. <br /> r <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Y2S ❑ NO Describe <br /> FORMATION <br /> -' H not known,indicate estimated formation log from nearby well or boring PUMP ._ � /�f+� � <br /> 'v� t/� <br /> Type ✓ <br /> Removed ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PerforatioNRemoval <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> € <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,o/ne'�bag of�entonite-50 Ibs.) / - <br /> Grouting Matenal������� Q to�..L 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 well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Don Scodola �7eI1 �3c3.ilin� Co,. Icic. 27172 <br /> Contractor Business Name License or Registration No. <br /> „"",--" �,��,�—i.f J <br /> A 'e . n -Signature". Date <br /> �OCAL COPY <br /> H ��.�5 5 c:�mck Moore <br /> Name ol Person Sealing Well or Boring <br />