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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H Z 617 0 4 WELL AND BORING SEALING RECORD Sealing No. County Name Minnesota Unique Well No. _ Minnesota Statutes, Chapter 103i or W-series No. � ' J�, " �Leeve blank i�na�known) Township Na e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed '/.� '/: �. � ' �y� ! GPS Latitude degrees minutes_ seconds Depth Before Sealing /� �S� ft. Original Depth ft. LOCATION: Longitude___ degrees_._. minutes___ seconds pQUIFER(S) STATIC WATER LEVEL ' Numerical Street Address or Fire Number and City of Well or Boring Location � ,Single Aquifer �J Multiaquifer p/�,�, ; WELUBORING Measured j_�Estimated Date Measured,��J�� fl/``4'— � j Water-Supply Well ❑MoniL Well + Show exact bcation of well or boring Sketch map of well or boring �( � in section grid with"X° location,showing property ❑Env.Bore Hole ❑Other �i ft. �I below L above land surface N lines,roads,ancj b�ildings. CASING TYPE(S) �' '. --'-- --'--- --`-- --'-- - � � N k i _�� _� `, Steel ']Plastic ❑Tile ❑Other z I ; I I �•� �_ --�'-'"�--- "-�-- --'`-- 4�� WELLHEAD COMPLETION �� : W : ; ; � ET �:�. � � � � Outside: ��Well House ❑At Grade Inside: �_'j Basement Offset , 'h M'ie �Pitless AdapterNnit ❑Buried ❑Well Pit ; I ; I ; I d --�--- --�-- --�-- ---•-- � _. ❑Burie ; L ( [�Well Pit S ❑Other � 1 Mile--{ L�Oth2f � PROPERTY OWNER'S NAME/COMPANY NAM CASING(S) Diamfet�rr � Depth � Set in oversize hole? Annular space initially grouted? Property owners mailing address if diflerent than well location address indicated above C./ � �_ to��S ft. i�Yes ��No �Yes U No U Unknown _f_in.from �� Cacl Bolarxier a � �y in.from ro ft. ��Yes ❑No ❑Yes ❑No �Unknown 251 STacke� St .St � A!N 55207 in.from to ___ft. I]Yes �No ❑Yes ❑No ❑Unknown WELL OWNEF'S NAME/COMPANY NAME SCREEN/OPEN HOLE r � Well owner's mailing address if tlifferent than property owrer's address indicated above Screen fromf�__�to ? ft. Open Hole from to ft. OBSTRUCTIONS ;Rods/Drop Pipe ❑Check Valve(s) ❑Debris ',.='Fill ❑No Obstruction � Type of Obstructions(Describe) ��fN�� Tl� g ��„�� i GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? Yes ]No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. �� .�'y�� Type � }�'�`� °�-� ��!�emoved ❑Not Present ❑Other 2 �� METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �fVo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe �J Casing Perioration/Removal !� in.from to ft. ❑Perforated Lj Removed _ in.from to ft. ❑Perforated ❑Removed - � Type of Perforator ' �_'��,Other--------------�-------- - ": _ d GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) ,ry�� I � Grouting Material '� �_[�!'-��from�,�., to�� ft. __ yards f�_ bags _ from___ to R _ yards_____ bags �� from to__ _ _ k._._,____.__ yards___._.___ bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES!N 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 Stodola t�e1l Drillirig Co,, Irnc 1691 � ----- --_---- — ----- — - — � Contractor Business Name � License or Registration No. - "'.3 �.� �/ �., 7 - --- �Representative SignBt Certified Rep.No. Date � . LOCAL COPY H /y�� "_�,,". ._�t �•=` i_...�.v_ � 2�,/��O� Name of Person Sealing Well or Boring �� `� � � HE-01434-09 IC#140-0423 - s/osR