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Minnesota Well and Boring
Sealing No.
Minnesota Unique Well No.
or W-series No.
(L....b...'II004..nownJ
IH
I
?1?584
I WELL OR BORING LOCATION
IC~
MINNESOTA DEPARTMENT OF HEALTH
WELL AND BORING SEALING RECORD
Minnesota Statutes, Chapter 1031
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Latitude~_!idegreeS~minules~seconds
LOngitu~ 'I 3 degrees ~minutes t11 seconds
GPS
LOCATION
15e;il:;e:;ddrc;:;::;::r~W~LOC;i:nE ,
Show exactlocaHon 01 well-or borint "I . .J.. ~ , Sketch map 01 well or boring
In section gnd With "X:iJ~ ~ location, showing property
N-"...,.~,roads,andbUildings.
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I~NAMElCOMPANY'NAME!' /(~
Property owner's mailing address il dilferenl lhan weUlocabon address in dicaledabove
WELL OWNER'S NAME/COMPANY NAME
Well owner's mailing address if dlllerent lhan property owner's address indicated above
I GEOLOGICAL MATERIAL !
COLOR [HARDNESS ORI FROM I TO
FORMATION
It rlOI krlown, irldicala estimated formaliorl Jog Irom rleart:ly well or boring
.17~
o
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
~~~et~rA.
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COpy I H
212584
il
Date Sealed
Date Well or Boring Constructed
q- if-03
/3 b
13 b
Depth Belore Sealing
I AQUIFER(S)
!J Sirlgfe Aquiler 0 Mulliaquifer
WELUBORING
. Water Supply Well 0 MOrli!. Well
o Env, Bore Hofe
ft. Original Depth
ft
STATIC WATER LEVEL
. Measured D Estimated
/-fO
o Other
ft. _befow
o abovelandsurtace
CASING TYPE(S)
. Steel 0 Plastic 0 Tile 0 Other
WELLHEAD COMPLETION
Outside: D Well House
Inside: . Basement Offset
o Pitless Adapter/Unit
o Well Pit
OWeUPlt
o Buried
o Buried
CASING(S)
Diameter Depth Set in oversize hole? Annular space initiaily grol.lted?
~;n from ., to J 3/ ft. DYes .No DYes o No D Unknown
_in. from to ft. DYes o No DYes o No o Unknown
_in. from to ft. DYes o No DYes o No o Unknown
SCREEN/OPEN HOLE
J 3 / to
136ft.
I Screen from
OBSTRUCTIONS
. Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill 0 No Obstruction
6 3 ' .~ , . ~E
Type of Obstructions (Describe) ,~OJ! ~~. ~~
'5- .. " I' ,
a-.J ~.
Open Hole from
to
ft.
Obstructions removed? . Yes 0 No
PUMP I ,_ _ . ".Il A
Type~
Is 6 . Removed 0 Not Present 0 Other
Describ'"
l METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE;
,_ No Annular Space Exists
I
o Annular space grouted with tremie pipe
o Casing Pertoration/Removal
in. from
o Perforated
o Removed
to
ft.
in, from
o Perforated
o Removed
to
ft.
Type of part:::::-ut.....
o Other
GROUTING MATERIAL(S) (One ~g of cement" 94 Ibs., one beg of bentonite" 50 lb..)
Grouting Material ~ ~om 6 10 J 3 bft yards J 3 fbagS
from
ft.
yards
to
bags
Irom
ft.
yards
bags
to
I OTHER WELLS AND BORINGS
I Other unsealed and unused well or boring on property? 0 Yes . No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The information conlained in this report is
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Contractor Business Name '.s 6 0 7/
~~
Authol1zed Representative Signature
~ Lfo J 7/-f
License or Registration No. -
Date
/<~~
Name of Person Sealing Well or Boring
,,;,,,., 0