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WELL OR BORING LOCATION
County Name
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MINNESOTA DEPARTMENT OF HEALTH
WELL AND BORING SEALING RECORD
Minnesota Statutes, Chapter 103/
Minnesota Well and Boring
Sealing No.
Minnesota Unique Well No.
or W-series No.
(lM.... blank II no! known)
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Township No. Range No. Secllon No. F~io~m i)) Date Sealed
112f '-'- 10 wrC"'W JI-~-OS
Latitude .!t...!i degrees ..!:t-L minutes S I ~onds ?- 0 If
Depth Before Sealing
LOngitudeO 'l3dagreeS Uminutes ~seconds
AQUIFER(S)
Numerical Street Address or Fire Number and City of Well or Boring Location . Single Aquifer 0 Multiaquifer
3 3 b b E J 8 0 ;;(ii.., ~ jJ ~ ~ WELUBORING
, . Water Supply Well
Show exact location of well or boring N"'" Sketch map of well or boring
in section grid with "X" location, showing property 0 Env. Bore Hole
N .-J.... /. ,I "'l.. ~~; lines, roads. and buildings.
~ I'v.. ~ S..J~ CASING TYPE(S)
~+..+..+J.+. II a ~ (8 . Steel 0 Plastic 0 Tile 0 Other
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..,..... -:-. no,....' ,... .h1lY- ~ ) WELLHEAD COMPLETION
W, , , 'E ' ~~ I
:, I, :, I, I '
~ _ _~ .. _ u!__ . .. ~_.. .. ~_.. T ~ I Outside: 0 Well House
L..~ .. ~_.. .. 1... ..l... l>>miIo J 8 0 ~ ",.;b E. I . Pitiess Adapter/Unit
r: : S : I: ~ I o Well Pit
~ '.... + ~ /' 0 Buried
11f" IC/O
/'10 Iqe
Iq8~o~
't.,OJ.f. tole; 0 Other
1::2.. J 0 I ,. J S". GROUTING MATERIAL(S) (One bag of cement = 94 Ibs., one beg of bentonite = 50 Ibs.)
~J 511-- 3 ~ )3routing Material ft.e"ct; ~ from 3 to ,.. () If ft. yards
I from to ft. yards
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GPS
LOCATION:
I PROPERTY OWNER'S NAME/COMPANY NAME
Property owner's mailing address jf different than well location addr.ss indk:ated JOOve
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I WELL OWNER'S NAME/COMPANY NAME
Well owner's mailing address jf different than property owner's address indicated above
COLOR IHARDNESS ORI FROM I TO
FORMATION
If nOI known, indicate estimated formation log trom nearby well or boring
GEOLOGICAL MATERIAL
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REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
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H 242908
Date Well or Boring Constructed
ft. Original Depth 1- 0 'I
STATIC WATER LEVEL
ft.
. Measured 0 Estimated
o Moni!. Well
o Other
---.J 0 'L. ft . below
o above land surface
Inalde: 0 Basement Offset
o Well Pit
o Buried
CASING(S)
Diameter
If in. from 0
Set in oversize hole?
Annular space initially grouted?
Depth
to J b? ft.
DYes .No
DYes
o No
o Unknown
in. from
to ft.
DYes 0 No
DYes
o No
o Unknown
in. from
to ft.
DYes 0 No
o No
o Unknown
DYes
SCREEN/OPEN HOLE
Screen from
to ft.
/67 to 1-0 if ft
Open Hole from
OBSTRUCTIONS
II Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill 0 No Obstruction
Type of Obstructions (Describe) J 3 Jf~ o.,t ~.~ I .~
"
~7'-~
Obstructions removed? 0 Yes 0 No
PUMP ~
I.f ~ Type
.. Removed 0 Not Present 0 Other
1 Ii v METHOD USED TO SEAL'ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
I 'I ~ . No Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal
in. from to ft. 0 Perlorated 0 Removed
Describe
in. from
o Perlorated
o Removed
to
ft.
Type of perlorator
?-/
bags
bags
from
ft.
yards
bags
to
OTHER WELLS AND BORINGS
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 contained In this report 1$
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.309 S-. ~~ 'h.ew--"~ tfO/7tf
Contractor Business Name ~ . .S"'6 () ? 1 License or Registration No.
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Authoriztfd Representative Signature Date
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Name of Person Sealing Well or Boring
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