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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring WELL OR BORING LOCATION Sealing No. H Countyl�a�m�e WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes, Chapter 103! or W-series No. (Leave blanN�il nol known) Township Nam Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed 118 23 33 AiL I� S� � GCT Q�i . GPS Latitude___ degrees minutes___ seconds Depth Before Sealing / �� ft. Original Depth ft. LOCATION: Longitude__ degrees minutes__ seconds UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑MWtiaquifer ��j� �� 2L,A7t! S�l�r �1�11 � �� 55356 �UB�RING _ Measured ❑Estimated Date Measurecl,J� � S �u�iater-Supply Well �]Monit.Well � Show exact location of well or boring Sketc f well or boring f '� in section grid with"X.° lo i ,sh � roperty ❑Env.Bore Hole �.''�;Other ft. �below ❑above land surface N I� e�d�,and l�ildings. CASING TYPE(S) .: --'--- --i-- --`-- ---'-- � Steel ❑Piastic '_,,Tle �Other --'-----�--- "`"-'->" WELLHEAD COMPLETION W ; ; : ; ET � � � � Outside: ]Well House ❑At Grade Inside: ❑Basement Offset h --�-----�--- --%'— --�-- - � , � 'h nniie �itless Adapter/Unit u Buried ❑Well Pit � � � � ' --;-"—� - —„' --�- - ❑Buried ' �� ❑Well Pit � ❑Other— -- �.f: �—i Mile�� ' ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diamet�i� � Depth � Set in oversize hole? Annular space initially grouted? Property owner s mailing address if diflerent ihan well location address indicated above `� in.from � to ` ��/ ft. ❑Yes [�o ❑Yes ❑No [!Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No C]Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r /� � Well ownePs mailing address if diflerent than property owner's address indicated above SCfeen ffom_ /�/to /�✓ R. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) []Debris ,�Fill �lo Obs[ruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR MARDNESS OR FROM TO Obstructions removed? ❑Yes �]No Describe FORMATION - PUMP If not k�own,indicate estimated formation log from nearby well or boring. - T pe /'� /� �✓ •"� !Removed �Not Present ❑Other __ 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 __ in.from _to ft. ❑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.) A` s ,r}� [,� / Grouting Material``��A� �(��j Gom v to �� +.� ft. yards� bags from to ft. _ yards bags from to ft. _ yards bags OTHER WELLS AND BORINGS HEMARKS,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 is true to the best of my knowledge. Dcx� Stodola Well Drfll3ng Cc�., Iric. 1692 Licensee Business Name - License or Registration No. . f� /O /' („/ � i e ative SignatGre�. Certilied Rep.No. Date < � 4 � � , �_^,��Y H 282684 _ ___- - � C�y:.��-� : Name of Person Sealing Well or Boring �. HE-01434-11 IC#140-0423 . 2'oeR S .rasax.m ... . .._ . . . - r r�X:.+.-..W � .. 6 e_.r...wu .., t...._,. c.......,.u,�n r.v.uu.n....�rv m«..�_ ...�:_ ..s�..,,x. . �x�..�_..,....,�..