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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' ��O C WELL AND BORING SEALING RECORD Sealing No p County Name Minnesota Unique Well No. Minnesota Statutes, Chapter 1031 o�rgW-seneskNo. } _� ��r _ Township Na Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Oro�o 118 23 27 3a�-0(�319'� 21 F=r� �`.� f/- �.�' `�'� �` , GPS Latitude degrees minutes seconds Depth Before Sealing �L�J ft. Original Depth �-�J`�J ft. IOCATION: Longitude degrees minutes seconds pUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and Ciry of Well or Boring Location Single Aquifer [j Multiaquifer /� ! ` 2335 St�dowovd Dr, tic�ono 55356 WELUBORING �Measured [�Estimated Date Measured.�✓�l� �J�l� 4 �Water-Supply Well ❑MoniL Well Show exact location of well or boring Sketch map of well or boring r Env.Bore Hole in section grid with"X" �� location,showing pro�perty �-� L.i Other �� ft. �below f]above land surtace N , ' ines,roads,andbulldTas. , :y'-_•�. ,y,"s-.?�•3 d y • CASING TVPE(S) �� --'-- - �--- ---`-- ---'-- � 6 ��o �Steel �,Plastic ❑Tile ❑Other . > �. � � � , �� i .``: � --'-----'--- ---��-- ---;`` � .�� WELLHEAD COMPLETION �� W ; ; ; ; ET __;___ __;___;____r_ Outside: ❑Well House ❑At Grade Inside: []Basement Offset ` ' , , , , '/M'ie � �Pitless Adapter/Unit ❑Buried [�Well Pit '� --�-----�----�- I ❑Buried ,�: , , S , , 1 I]Well Pit �- -� ❑Other I_]Other_ _ 1 Mile PR ERTY O R'S�}�1 E/COMP Y NAME CASING(S) ." ��t'j�� Diam tef� �1 � Depth , Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different ihan well location address indicated above in.from to ' Q' ft. �� -/ � ❑Yes �No [�Yes ❑No ❑Unknown in.from to ft. �]Yes ❑No ❑Yes ❑No ❑Unknown - ' � `7 in.from to ft. ❑Yes ❑No j�Yes ❑No �]Unknown c�� WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � � ry/'�/� / Well owner's mailing address if different than property owner's address indicated above SCreen from� j� to G��^CJ ft. Open Hole from to ft. OBSTRUCTIONS �Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction ,� Type of Obstructions(Describe) �/l//l/�_f_��T/'"r" } �� ; GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe � PORMA710N If not known,indicate estimated formation log from nearby well or boring. PUMP Type �L�G 1��n r� j - `''� [�Removed ❑Not Present ❑Other !� METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: '� � 1�10 Annular Space Exists i.�Annular Space Grouted with Tremie Pipe []Casing PerforatioNRemoval �� _ in.from to R (�Perforated [_�Removed ? in.from to_ ft. ��Perforated ❑Removed Type of Perforator _ ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) ♦ � ^ / ' Grouting Material /VL!-�l �,'J�,L��l�om� to�[;,�� ft. yards�(�y bags from to ft. yards bags E _ from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes o 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. Don Stalola Well__Ik�i.11ing Co�. I�. 1691 j' Licensee Business am "��- License or Registration No. �, „ > ',—J' ;� � �,� ; ili resentative Signature. Certified Rep.No. Date � f�.... ;��,�ai_COPY H 2 S V�O� l+�'��`v Name of Person Sealing Well or Boring z HE-01434-10 IC#140-0423 ' 5/o7a ��