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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I ��O�� County Nam$ WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No. � Minnesota Statutes,Chapter 1031 or W-series No. � in «aa�a e�e�k�,�o,k�ow�, Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed drono 326 23 27 32�-O�bl�' 2,.1 �� r Q� Q/� , GPS Latitude degrees minutes seconds Depth Before Sealing �Q V ft. Original Depth ft. LOCATION: Longitude degrees minutes seconds � A IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and Ciry of Well or Boring Location ingle Aquifer ❑Multiaquifer �/.,� /�,f� - 2335 Si�+do�od Dr, �� 5535b ,�[ UBORING �Measured ❑Estimated Date Measured S /�'_ '� r� L�JVJater-Supply Well ❑Monit.Well � _ Show exact location of well or boring Sketch map of well or boring �ZC} in section grid with"X:' location,showing property �i Env.Bore Hole ❑Other _ tt. �below ❑above land surface N - �F� lines,roads,pndtbpikli�s. CASINGTYPE(S) �x�c.�_�trSSCh� !J --'-----'--- ---`-- --'-- � `�Ip [�teel �Plastic ❑Tile ❑Other �* I I I I �� ,- I I I I i ^ ' •, --'--- --'--- ---`-- ---�-- • �� WELLHEAD COMPLETION �- ��. W � � � � E� M . �;� __;___ __,___ __;__ __;__ Outside: ❑Well House �At Grade Inside: []Basement Offset ��-' :� , , , , 'h M�ie itless A p r/Und ❑Buried ❑Well Pit .. , , , , � ❑P� da te � ' --�--- –�----�-----�- .. I]Buried S []Well Pil ❑Other �i M�ie� ❑Other _ PROPERTY OW ER'S NAME/COMPANY NAME CASING(S) St��ICathleen J�t�s�ston Dia ef�r t Depth � Set in oversize hole? Annular space initially grouted? Properry owner's mailing address if different than well location address indicated above �� /� to��_ft. Yes No YeS No m.from ❑ � ❑ ❑ ❑Unknown a in.from to ft ❑Yes ❑Na ❑Yes ❑No ❑Unknown 2 Q� 2 in.from to ft. ❑Yes ❑No []Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE / 1 � Well owner's mailing address it different than property owner's address indicated above SCreen from�Yi�to�ft. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe [�Check Valve(s) ❑Debris ❑Fill �No Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO ObsV�ctions removed? ❑Yes ❑No Describe - FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. f�j Type drfft � �'"" �Removed �j Not Present ❑Other � � � i METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal _. in.from to ft. ❑Perforated L�Removed - in.from to R ❑Perforated L;Removed Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �.^ � � „" Grouting Material/�+�/-�/ ��1�%/–�iU/from� tq��.� ft.___ yards� bags � from to ft. yards bags from to ft. yards bags - � OTHER WELLS AND BOR�NGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? [J 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 ,t is true to the best of my knowledge. Do� Stodola We21 Dcilling Co,. I�. 1692 Licensee Business Name License or Registration No. �, �� ' 2�2/—lJ0 ,�� ertified e resentative Sigv�tu�e Certified Rep.No. Date LOC,4L CGPY H /N�Z�� ------U�I AIjLO� �L.V Name of Person Sealing Well or Boring HE-01434-10 ICn 140-0423 sio�a� .