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� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I �O Q��� <br /> County Name WELL AND BORING SEALING RECORD Mennlego a�Unique Well No. `�Q ` <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (leave blank i not kn wn) <br />, Towns ip am Township No. Range No. Seciion No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Oraio 127 23 I7 N� N9� S� 22 J�1N 14 <br /> , <br /> GPS Latitude degrees minutes seconds Depth Before Sealing ��� ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds AQUIFER(S) STA71C WATER LEVEL <br /> Numerical SVeet Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Multiaquifer /�Qy/ <br /> �W L/BORING �i Measured ❑Estimated Date Measured�� IJ(71 <br /> Water-Supply Well ❑Monit.Well � <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X." location,showing property � i Env.Bore Hole ❑Other l�_ft. �below ❑above land surface z <br /> N `� lines,roads,and buildings. CASING TYPE(S) z <br /> ° --'-----i-- ---`-----'— <br /> � <br /> ,\ �Steel ❑Plastic ❑Tile ❑Other <br /> �% I I I I � `l' <br /> -- --------- --- ----- -- WELLHEAD COMPLETION <br /> W ; ; ; ; ET <br /> ' � I _;_ ___;__ � � , utside: ❑Well House rl.At Grade Inside: ❑Basement Offset <br /> ��. O � � <br /> . ------------ - <br /> � � � � � 'h Miie � ss A p r/Un t �)Buried ❑Well Pit <br /> .,, <br /> � , , � � � <br /> , , , , �P'itle da te i <br /> ��i --;----T-- ---�—---:-- I_.-.....� ' � i�Buried ;:. <br /> ' ' ' ' L � ❑Well Pit <br /> S ]Other <br /> �7 Mile� ❑Other <br /> PRp�pp.E.R.TY OW�7�,E�R'S�}1,AM COMPANY NAME CASING(S) <br /> y«� •`�+�t`+ ��• Diame r�� � Depth � Set in oversize hole? Annular space initially grouted? <br /> � Property owner's mailing address if different ihan well location address indicated above ��n.from `✓ to�ft. ❑Yes �No ❑Yes No <br /> � �t O a��� `� ❑ ❑Unknown <br /> , <br /> _ TOL'ljCS Btlj,� � n55331 in.from to ft. ❑Yes �]No []Yes n No ❑Unknown <br /> in.trom to ft ❑Yes []No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � / Y <br /> Well owner's mailing address if different than pioperty owner's address indicated above Screen from �� to�g� fl. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> [Rods/Drop Pipe ❑Check Valve(s) []Debris ❑Fill ❑No Obstruction <br />� Type of Obstructions(Describe) p.l���_ _,�/'LJ�a(4 <br /> GEOLOGICAL MATERIAL COLOR NARDNESS OR FROM TO Obstructions removed? es �1 No Describe <br /> FORMATION <br /> PUMP � <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> Type <br /> ��� �"- �� � f ��� ❑Removed �Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. [Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator ___ <br /> ��']Other - <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> , � - <br /> _ Grouting Material�i��/���� from_�_ to�_�8 ft. yards !/� bags <br /> r y <br /> from to ft. yards bags <br /> from to ft. yards_____ bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �,�Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report - <br /> is true to the best of my knowledge. <br /> Don Stod�la Well_Drilling Co,, Inc. 2691 ' <br /> Licensee Business Name � 1 License or Registration No. <br /> 1��.—�---...� �•. <br /> f .�/ /��� i�e'�� 'a'�.r} � _4 <br /> rtifie epresentative Signature Certilied Rep.No. Date <br /> . •..�, -. y �..,, �n`i a 4.fi_�t y�.J <br /> LOCAI �:O?Y H 2 8 8 9 5 6 Name of Person Sealing Well or Boring <br /> HE-07434-12 IC#140-0423 �.� siosa <br />