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3255 Sibley Memorial Hwy - Well & Boring Sealing Record 2021-12-29'25 6ibic' WAIL Show exact location of w I or boring in section grid with "X." w s 1 Mile 'h Mile WELL OR BORING LOCATION County Name DC0'4) CI—CL/ Township Name tt MINNESOTA DEPARTMENT OF HEALTH WELL AND BORING SEALING RECORD Minnesota Statutes, chapter 1031 Minnesota Well and Boring Sealing No. Minnesota Unique Well No. or W-series No. (Leave blank if not known, Township No. Range No. 1?:' Section No. Fraction (sm. —, Ig.) 5 Li4 Date Sealed 1 u GPS<1r_CATION — decimal degrees (to four decimal places) Latitude Lcngitude Depth at Time of Sealing 31 5 _ ft. Numerical Street Address or Fire Number and City of WeII or Boring Location 4 56121 Sk- ch r of well or boring location, showing property Tines, roads, and build pgs. For temporary borings, provide additional location information, a site sketch, and geology on a separate page. AQUIFER(S) j, Single Aquifer ❑ Multiaquifer WELUBORING j Water -Supply Well ❑ Env. Well ❑ Temp. Boring ❑ Other PROPERTY OWNERS NAM _/COMPANY NAM Crni (Lc n Propefty owner's mailing address if different th well location address indicated above 25) Av-Ls-5- 41 y n . , 71 t '--I WELL OWNER'S NA E/COMP NY NA E ell oviner's mailing address if different than property owner's address indicated above kA-CtJ)3 .t\V" 1011-eapo 161 CASING TYPE(S) Date Well or Boring Construct I\JA- Original Depth ti Aft. STATIC WATER LEVEL Measured Date Measured 53!/*24 ❑ Estimated 72. ft. elow above land surface teel ❑ Plastic ' Tile ❑ Other WELLHEAD COMPLETION Outside: ❑ Pitless Adapter/Unit ❑ Well Pit ❑ Other ❑ At Grade ❑ Buried Inside: ❑ Basement Offset ❑ Well House I Well Pit uried ❑ Other CASING(S) Dia, eter Depth Set in oversize hole? Annular space initially grouted? in. from to C ft. ❑ Yes '`'gNo ❑ Yes ❑ No Unknown in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown SCREEN/OPEN HOLE Screen from to ft. Open Hole from to =1 ft. GEOLOGICAL MATERIAL COLOR HARDNESS OR FORMATION FROM TO If not known, indicate estimated formation log from nearby well or boring. NA - OBSTRUCTIONS ,Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction � -. Type of Obstructions (Describe) t ZO t CLA '(' Pia_typ Obstructions removed? XYes ❑1 No Describe PUMP ❑ Not Present [Present, Removed,Prior to Sealing ❑ Other Type6u_brney-3I : METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE No Annular Space Exists Annular Space Grouted with Tremie Pipe ❑' Casing Perforation/Removal asing Diameter in. from to ft. ❑ Perforated ❑ Removed in. from to ft. ❑ Perforated ❑ Removed Type of Perforator REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING VARIANCE Was a variance granted from the MDH for this well? ❑ Yes )Jo TN# GROUTING MATERIAL(S) Grouting Material t\ICs-'from , to d✓ ft. yards 2.1-+ bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? P1 Yes XrNo 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 is true to the best of my knowledge. trc, by--) p()_ci iS(‘,0 Licensee Business Name License or Registration No. 214 Vi—II22 Certified Representative Signature k-Ao. ht Certified Rep. No. Date Name of Person Sealing Well or Boring 11/19R HE-01434-17 ID# 53159