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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I ��c�O�{ <br /> C�inty Na���� <br /> WELL AND 60RING SEALING RECORD Mnnesoa�UniqueWellNo. J 1' <br /> KEN��pIN Minnesota Statutes,Chapter 103/ or W-series No. <br /> (Laeve blank�i�not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—�Ig.) Date Sealed Date Well or Boring Constructed <br /> OROAiO I18N 23W 28S SE N� �i+i ��'2, �i�N /Q <br /> r <br /> GPS Latitude degrees__ minutes_ seconds Depth Before Sealing ft. Original Depth ft. <br /> LOCATION: Longitude__ degrees___ minutes seconds �FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> W LL/BORING Measured ❑Estimated Date Measured���j�� <br /> Y RD � 6 ORON�i. MN• Water-Supply Well ❑nnona.wen ,, , <br /> Show exact location of well or boring 55�.356Sketch map of well or boring i Em.Bore Hole <br /> in section grid with"X." location,showing property ��� ❑Other_ �`"__�__ft. �elow ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> .. --'---—`-- ---`-- ---'-- �. <br /> \ Steel ❑Plastic ❑Tile ❑Other <br /> -- --------- - - ------ '�"j WELLHEAD COMPLETION <br /> , .. .. <br /> ; W � � � � <br /> �� ' ' ' ' � �"'��� Outside: ❑Well House ��� <br /> __,_____,___ __,_____,_ ❑At Grade Inside: ❑Basement Offset <br /> , , , , , nniie dless A p r/Urnt U Buried �Well Pit <br /> �� <br /> , , , � �P' da te <br /> --�--- --�------�----�-- <br /> [�Well Pit ❑Buried <br /> S <br /> ' i nniie� � ❑Other ❑Other <br /> i <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � Diame(((eee�� � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailin ere n ation address indicated above � / ?/ � � � �No ❑Unknown <br /> �in.from to��_�ft. Yes No Yes <br /> $$m@ in.from to ft. ❑Yes ❑No ❑Yes ❑Na ❑Unknown � <br /> c612-840-9470 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE /// , <br /> Well owner's mailing address if tlifferent than property owner's address indicated above Scfeen from�,��_to�h Open Hole from to ft. <br /> OBSTRUCTIONS <br /> y ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction <br /> i <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No'����Describe <br /> FORMATION <br /> If not nown,indicate estimated formation log from nearby well or boring. PUMP �� � <br /> /"� Type <br /> �✓ �Q ❑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 /> i� <br /> � <br /> ❑Other <br /> 'i GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> t � � <br /> Grouting Material^,����f���/from� to��ft. yards�� bags <br /> from to ft. yards bags <br /> �_ <br /> from to ft. yards bags <br /> i' <br /> �` OTHER WELLS AND BORINGS <br /> REMAHKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes ' No How many? <br /> i <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION " <br /> f 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 STODOLA fiTELL D1t T r.L T NG ��.�^� � �^- <br /> Licensee Busmess f �--. . ,. L�cens trahon No. �.. <br /> f _ <br /> i �. ,,. , f� 558 <br /> 1 C rtifie Representative Signature� Certilied Rep.No. Date <br /> �� Fi /�/� . �,'"�,,,'`r'-' <br /> LOCAL COPY /y(��0� Name o/Person Sealing We/l or Boring <br /> f�V i <br /> � HE-01434-11 IC#140-0423 f 2/OBR <br /> ` <br />