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HE -01434-16 ID# 63159 % 9117R <br />MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br />Sealing No. <br />WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br />Minnesota Statutes, Chapter 1031 Or W -series No. <br />" J 3 7 5 5 9 a <br />WELL OR BORING LOCATION <br />County Name <br />TT <br />Township Nam <br />01 <br />Township No. <br />117 <br />Range No. <br />23 1 <br />Section No. <br />17 <br />Fraction (sm. –� Ig.) <br />Date Sealed <br />yr ✓.L <br />Date Well or Boring Constructed <br />GPS LOCATION – decimal degrees (to four decimal places) <br />Latitude Longitude <br />Depth at Time of Sealing /q�ft. <br />Original Depth h. <br />AQUIFER(S) <br />Single Aquifer ❑ Multiaquifer <br />STATIC WATER LEVEL <br />✓ <br />Measured Date Measured ) ) El Estimated <br />ft. g below ❑ above land surface <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />1P75n o 1, )" h. <br />WELLBORING <br />} Water -Supply Well ❑ Env. Well <br />❑ Temp. Env. Well ❑ Other <br />Show exact location of well or boring r r e ch map Qf well or boring <br />in section grid with "X" 5 5 - adcation, showing property <br />N lines, roads, art b dlhgs. <br />CASINGTYPE(S) <br />steel ❑ Plastic ❑ Tile ❑ Other <br />--'--- --'r-- ---------- <br />'-- - <br />W i I l ET <br />__Y-_ ___�------ r <br />tk Mile <br />--4--- -------------------- I <br />s l1 <br />�1 Mile—� 0 Y l'' <br />For multiple temporary environmental wel(s!�vfde additional loc VU <br />WELLHEAD COMPLETION <br />Outside:�Piiless Adapter/Unit ❑ At Grade Inside: El Basement Offset <br />❑ Well Pit ❑ Burled Well House <br />❑ Well Pit <br />❑ Other <br />❑ Buried <br />❑ Other <br />CASING(S) <br />information, a site sketch, and geology on a separate page. ` <br />Diameter Depth Set in oversize hole? Annular space initially grouted? <br />l in. from to-"- 7 ft. ❑ Yes �No ❑ Yes ❑ No ❑ Unknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Q <br />Property owner's mailing a ress d ifferen t an wel oration address indicated above <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />In. from tc ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />SCREEWOPEN HOLE <br />toit. Open Hole from to ft. <br />Screen from� <br />WELL OWNER'S NAME/COMPANY NAME <br />OBSTRUCTIONS <br />YRods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />Well owner's mailing address if different than property owner's address Indicated above <br />Type of Obstructions (Describe) A– <br />Obstructions removed? Yes ❑ No Describe <br />PUMP <br />Present resent, Removed Prior to Sealing <br />❑ Pg ❑ Other <br />Type – - <br />GEOLOGICAL_ MATERIAL <br />COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TONot <br />If not known, indicate estimated formation log from nearby well or boring. <br />METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BOREHOLE <br />No Annular Space Exists ❑ Annular Space Grouted with Tremae Pipe E] Casing Perforation/Removal <br />_ <br />asing Diameter <br />in. from to ft. ❑ Perforated ❑ Removed <br />In. from to ft. ❑ Perforated ❑ Removed <br />Type of Perforator <br />VARIANCE <br />Was a variance granted from the MDH for this wail? ❑ Yes XNo TN# <br />GROUTING MATERIAL(S) (One bag of cement = g4 lbs., one bag of bentonite = 50 lbs.) <br />Grouting Material frpmr to�� % ft. yards bags <br />from to ft. yards bags <br />from to It. yards bags <br />OTHER WELLS AND BORINGS <br />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 />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />is true to the best of my knowledge. <br />Dan Stodola Well Drilling Co., Inc. 1691 <br />Licensee Business Name License or Registration No. <br />gAi �i; resen ague"Sig ure Certified Rep. No. Date <br />LOCAL COPY <br />JH 3 7 5 5 9 9 <br />Name of Person Sealing Well or Bor! <br />HE -01434-16 ID# 63159 % 9117R <br />