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~SOTA DEPARTMENT OF HEALTH
WELL AND BORING SEALING RECORD
Minnesota Statutes. Chapter 1031
Range No. Section No. Fraction (sm ~ 19) Date Sealed
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WE1.L OR BOFUNG LOCATION
:::ounty Name
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rownship Name
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GPS
LOCATION:
Latitude _degrees _ minutes _ seconds
Longitude_degrees _minutes _secondS
'4umerical Street Address or Fire Number and City of Well or Boring Location
'hY' tL....
Sketch map of well r boring
location, showing property
lines, roads, and buildings.
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NELL OWNER'S NAME/COMPANY NAME
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Nell owner's mailing address if clifferentlhan property owner's address indicated above
Depth Before Sealing
3c()
AOUIFER(S)
Aquifer 0 Multiaquifer
WELLIBORING
9'water Supply Well 0 Manit. WeB
-D Env. Bore Hole 0 Other
CASING TYPE(S)
~I 0 Plastic 0 Tile 0 Other
WELLHEAD, COMPLE11ON
Outside: 0 Well House
Minnesot~ and Boring
Sealing No.
Minnesota Unique Well No.
or W-series No.
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211394
Date Well or Boring Constructed
t\ .. 1 k .' \ )".0 n
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ft. Original Depth
It.
STAnc WATER LEVEL
[)tMeasured 0 Estimated
{' ,-
( ..f -) ft. ~ow
o above land surface
Inside: 0 Basemenl Offset
~~-- - -- ~-~-~-~-~-'----~--~~~-~-~~~~----~---
DWellPiI
~ess Adapter/Unit
o Well Pit
o Buried
CASlNG(S)
Diameter Depth ,_
--2 in. from.--f..l-. to ~ ft.
Jl ut f:," '.IIL .-
--'=L in. from--L.lL to ~ ft.
_ in. from_ to_ ft.
SCREENIOPEN HOLE
Screen from
to
o Buried
Set in oversize hole? Annular spac-ynitiatly grouted?
DYes ~ DYes DNo o Unknown
~es DNo DYes DNo D Unknown
DYes ONo DYes ONo o Unknown
ft,
/) /_L~
Open Hole from ~ to
~XJ ft.
OBSTRUCTIONS
o RodslOrop Pipe D Check Valve(s) 0 Debris 0 Fill rfNo Obstruction
Type of Obstructions (Describe)
REMARKS, SOURCE OF DATA. DIFFlCULnES IN SEALING
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WELL CONTRACTOR COpy
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Obstructions removed? 0 Yes D No Describe
PUMP
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o Not Present 0 Other
OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
i(j No~ Space E_ 0 .~ """" ~ """.......... ~,aSing PerforalionIRemoval
!:f:-- in. from , 4 ~ to z.. 4~ ft. L)(Perforated 0 Removed
in. from
Type of perforator
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o Other
to
ft.
D Perforated
D Removed
GROUTING MATERlAL(S) (One bag of cement = 94 Ibs., one bag of bentonite = 50 Ibs.)
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Grouting Malerial ~/h '-=;\ t\\>.., T from_ to2li ft. ~-1Jards _ bags
OTHER WEllS AND BORINGS
from_ to_ ft. _ yards _ bags
from_ to _ It. _ yards _ bags
Other unsealed and unused well or boring on property? DYes 0 How many?
UCENSED OR REGISTERED CONTRACTOR CERnFlCAnON
This well or boring was sealed in accordance with Minnesota Rules. Chapter 4725. The information contained in this report is
true 10 /he best of my knowledge.
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License or Registral;on No.
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WELL AND BORING SEALING RECORD
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Sealing NO. ,
Minnesota Unique Well No.
or W-series No.
n.-_UftOt-'1
~.L.1.~~:)
:;ounty Name
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./t. ~..' '~
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Minnesota Statutes, Chapter 1031
GPS
LOCATION:
Latitude _ degrees _ minutes _ seconds
Longitude_degrees _minutes _seconds
'4jumi{en,'cal,s ?treett Address or Fire Number and City of wen or ~in. 9 ~ocation
/1 ." U A. or 1, l -.., Ie.' .Jfl ,1\. 1 . '.. . {.
""1' Hu.:J.W~..'O'. ILttKI K'U /\ ,t.~.l \,.. --'
"'OW exact location of well or boring Sketch map of well Or boring
n section grid with "X" location. showing property
lines, roads,. and buildings.
N
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)ROPERTY OWNER'S NAME/COMPANY NAME
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'roperty owner's ""ailing address if difterent than well rPlion addres,s ~t~ abov, e
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WELL OWNER'S NAME/COMPANY NAME
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WeD owner's mailing address it different than property owner"s address indicated above
GEOLOGICAL MATERIAL
HARDNESS OR FROM
FORMAnON
COLOR
f not knQW[l, indicate estimated formation log from nearby well or boring
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=tEMAAkS, SOURCE OF DATA, blFFlcUtTlESIN SEALING
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~tLCONTRACTORCOPY
IH
211395
Date Well or Boring Constructed
tf.c;.. () 3
?4-k
t;\ t \ \( \"\\.: \\) n
34t
ft. Original Depth
Depth Before Sealing
It.
*\olfFER(S)
~e Aquifer 0 Multiaquifer
WELUBORING
o Water Supply Well 0 Mooit. Well
o Env. Bore Hole 0 Other
CASING TYPE(S)
STATIC WATER LEVEL
[)'Measured 0 Estimated
\ (\ J:J ft. ~IOW
o above lana surface
~eel 0 Plastic 0 Tile 0 Other
WELLHEAD COMPLETJON
Outside: 0 Well House
[)IPitess AdapterlUnit
Inside: 0 Basement Offset
o Well Pit
o Well Pit
o Buried
o Buried
CASlNG{S)
Diameter Depth".
---1..J1 in. from----'-L- to ~ f1.
(ll (.: ;" .-,
----1 in. from~ to ~ ft.
-5L in. from - 2.1 to ~).,.~b.
Set in oversize hole? Annular space initially grouted?
DYes ~ DYes ONo o Unknown
Lj.'ffJs ONo DYes ONo o Unknown
~s ONo DYes DNo o Unknown
SCREENIOPEN HOLE
Screen from
t "1,2- to
?4 fe, ft.
ft.
Open Hole from
to
OBSTRucnONS
o Rods/Drop Pipe 0 Check Vatve{s) 0 Debris 0 Fill ~o Obstruction
Type of Obstructions (Describe)
TO Obstructions removed? 0 Yes 0 No
PUMP
/11.. Type :::.A\. \jy\\t '(''::1;\-;\ G
;~ j. [)CRemoVed 0 Not Present 0 Other
J ..'f
, --, METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
.'-;'.W 0 No Annu]'{. spac~ Exists 0 Annular space grouted w~tremie pipa c1-casing Perforation/Removal
. · ::J In. from 0 to 1,.' f ft. ri- Perforated 0 Removed
q in. from "" Z."1 to 't 2.'1.- ft.
'v\i y\ <:'.{~ ,
Describe
r:J. Perforated
o Removed
Type of perforator
o Other
GRounNG MATERIAL(S) (One bag of cement = 94lbs., one bag of bentonite = 50 fbs.)
\ ( '\ -'-';1-A - . /J t
Grouting Material N f h...J\ i..:;\.\. - from~ to ~ft. ~ yards _ bags
Ce-', l ,'... '~ \-\-
from_ to_ It. _ yards _ bags
from_ to_ ft. _ yards _ bags
OTHER WELLS AND BORINGS
Other unsealed and ~;e11 or boring OIl property? 0 Yes ~ How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This weI or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The inlormation contained in this report is
true to the best of my knowledge.
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Au/ed Repr~~a~ve ~::aJure<;~/~~~.
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Ucense or Registration No.
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Date
Name of Person Sealing Wen or Boring