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WELL OR BORING LOCATION
County Name
~
MINNESOTA DEPARTMENT OF HEALTH
WELL AND BORING SEALING RECORD
Minnesota Well and Boring
Sealing No.
Minnesota Unique Well No.
or W,series No.
(Leave blank II not known)
Minnesota Statutes, Chapter 103/
Jjl.wnshlP ~~me Township No. Range No. Section No. Sction ~... ~
~ //S ,.~ ?-S W' W E/o
Latitude ..!t...!t.... degrees ti minutes :?- "seconds
Lon/:?ude q:3 degrees'" Lf minutes 3 / seconds
GPS
LOCATION:
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Show exact location of well or boring N 1'" Sketch map of well or boring
in section grid with "X" I location, showing property
lines. roads, and buildinQs.
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PR07f~NAME/COMP~
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WELL OWNER'S NAME/COMPANY I'l'AME '
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Well owner's mailing address it different than property owner's address indicated above
I GEOLOGICAL MATERIAL I COLOR IHARDNESS ORI FROM I TO
FORMATION
IIf not known, indicate estimated formation log from nearby well or boring
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/8/ ~oq
').0 9 .13~
REMARKS, SOURCE OF DA,TA, 91FFICULTIES IN SEALING .L
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COpy H
212599
n 11:1
Date Sealed
Date Well or Boring Constructed
10- "-3--03
Depth Before Sealing -13 8
. AQUIFER(S)
. Single Aquifer 0 Multiaquifer
WELUBORING
. Water Supply Well 0 Monit. Well
o Env. Bore Hole 0 Other
CASING TYPE(S)
I Cf 8
ft. Original Depth
STATIC WATER LEVEL
. Measured 0 Estimated
108
ft. . below
.. Steel 0 Plastic 0 Tile 0 Other
WELLHEAD COMPLETION
Outside: 0 Well House
Inside: 0 Basement Offset
. Pitless Adapter/Unit
o Well Pit
o Well Pit
o Buried
o Buried
CASING(S)
Diameter
~ in. from
Set in oversize hole?
Depth
to /8/ ft.
o
DYes .No
in. from
ft.
o No
DYes
to
in. from
ft.
DYes
o No
to
SCREEN/OPEN HOLE
Screen from
ft.
18/
to
Open Hole from
H
?12S.99
ft.
o above land surface
Annular space initially grouted?
DYes
o No
o Unknown
DYes
o No
o Unknown
DYes
o No
o Unknown
to I Cf 8 ft.
OBSTRUCTIONS
. Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill 0 No Obstruction
Type of Obstructions (Describe) 13()~ ~ ~~. ~ ~
., )- I, ,..,-" ,
a-..L ~,
S"
leI
Obstructions removed? . Yes 0 No
PUMP D' --jJ 4_
Type ~
. Removed 0 Not Present 0 Other
Describ~'
to
ft.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
o Perforated
o Removed
. No Annular Space Exists
in. from
o Annular space grouted with tremie pipe
in. from
ft.
to
Type of perforator
o Other
o Casing Perforation/Removal
o Perforated
o Removed
GROUTING MATERIAL(S) (One bag of cement = 94 Ibs., one ball of bentonite = 50 Ibs.)
Grouting Material 'Ite-tJ;t ~rom-Y:-- to ll..a... ft. yards
Other unsealed and unused well or boring on property? 0 Yes . No How many?
UCENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The information contained in this report is
true to the best of my knowladge. ~ _ " ~
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3CJ8 E. ~~~.#'~
Contractor Business Name ~ S6 0'7/
~~
from to
LfO~ot-~~~
from to
OTHER WELLS AND BORINGS
Autho~ed Representative Signature
/(~
~
Name of Person Sealing Well or Boring
33
bags
ft.
yards
bags
ft.
yards
bags
'fO/7Jf
License or Registration No.
I~-
~O-03
Date