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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringLL,GiI I C O A <br /> County <br /> Na BORING LOCATION WELL AND BORING SEALING RECORD Minnesota loUnique Well No. J Q�l• <br /> 60 <br /> County Name <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank R not known) <br /> Township Narne Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed <br /> U <br /> i <br /> GPS Latitude degrees minutes seconds Depth Before Sealing ft. Original Depth ft. <br /> LOCATION: Longitude_ degrees_ minutes_ seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer li A�1 <br /> 305 Willow DC S, Olono, M 55356 WELL/BORING x1Measu/ed E]EstimatedDate Measured-... o <br /> Water-Supply Well F1 Monit.Well <br /> Show exact location of well or boring Sketch map of well o boring j <br /> in section grid with"X" location,showing pro erty�C ❑ ❑ <br /> Env.Bore Hole Otherft. below E]above land surface <br /> N ds,and buil n^�` CASING TYPE(S) <br /> --- - C O <br /> Steel ❑Plastic ❑Tile ❑Other <br /> ---f---- l WELLHEAD COMPLETION <br /> W E «33TT <br /> --- ---r <br /> Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> � "`..,� X Pitless Adapter/Unit ❑Buried ❑ <br /> Well Pit <br /> --T-- <br /> ❑Well Pit E]Buried <br /> S ❑Other <br /> )--1 Miley ,.f ❑Other _ <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameyerf,f / Depth r Set in oversize hole? Annular space initially grouted? <br /> Prope own is mai mg a dress 40,even an well location address indicated above 4L in.from to //&ft. E]Yes to ❑Yes ❑No E]Unknown <br /> n.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> n.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r <br /> Well owner's mailing address if different than property owner's address indicated above Screen from 1167 to , U ft. Open Hole from l0 ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill X No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION -- <br /> PUMP <br /> It�not <br /> 7fknown,indicate estimated formation log from nearby well or boring. <br /> �J © Type <br /> E]Removed Klot 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 lbs.,one bag of bentonite=50 lbs.) <br /> _ / <br /> Grouting Material!"jillio _ "'Mom 0 to/20 ft. yards 0 bags <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 No 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 •to&la well Drilling Co., Inc. 1691 <br /> Contractor Business Name License or Registration No. <br /> presentative Signatufel Certified Rep.No. Date <br /> LOCAL COPY " 2 5 8 4 6 4 <br /> Name of Person Sealing Well or Boring f, <br /> HE-01434-09 IC#140-0423 6/06R <br />