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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 8 8 3 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Slng NoUnique Well No. 8 0(� <br /> Minnesota Statutes,chapter 1031 or W-series No. <br /> pin ea a dank it not known) <br /> „HenneTownsffip Name Township No. Range No. Section No. Fraction(sm. Ig.) Date Sealed Date Well or Boring Constructed <br /> oro�m___ _� ust-2�15 s� 1 r - !to t 0 <br /> GPS LOCATION—decimal degrees(to four decimal places) /t�/ <br /> Depth at Time of Sealing / ft. Original Depth ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> • Numerical Street Address or Fire Number and City of Well or Boring Location 4Single Aquifer ❑Multiaquifer ' tJ,, } <br /> a yELL/BORING Measured Date Measured )ti - kJ° -v`6 ❑Estimated <br /> °I) • • .t.i# _' < .___ _s . $1 •.!i► Water-Supply Well ❑Env.Well �» • <br /> Show exact location of well or boring <br /> in section grid with"X." loc tion,showing property Temp.Boring ❑Other ft. [below El above land surface <br /> N lin:.,roads,and buildings. CASING TYPE(S) `_ <br /> ntf Steel ❑Plastic ❑Tile El Other <br /> '--'---__4_------`-------" \N WELLHEAD COMPLETION <br /> w-_-_-_ E T 4. Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: V.Basement Offset <br /> 'h Mile 1 ❑Well Pit ❑Buried ❑Well House <br /> 4.-------- --- 1 S ❑Other illWell Pit T I" <br /> S I ❑Buried <br /> I--1 Mile ..�� ��lp�, (f� El Other <br /> For temporary borings,providetadd�dffal locgtion - 12 CASING(S) • <br /> information,a site sketch,and geology on a separat ge. Dia ter Depth Set in oversize hole? Annular space initially ? <br /> � 6 p pgrouted. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from to `/ 1 tt. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> T Scheeler Demolition A ftcasating <br /> Property owner's mailing address if different than well location address indicated abov in.from to ft. ❑Yes ❑No El Yes ❑No <br /> ❑Unknown <br /> 11415 Valley Dr in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Rogers, 55374 SCREEN/OPEN HOLE /(,� <br /> WELL OWNER'S NAME/COMPANY NAME -` of 2 Screen from /4-1 I to / /++? ft. Open Hole from to <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above fy Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) [ \` ._ <br /> Obstructions removed? [Ties ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL 1 COLOR HARDNESS OR FORMATION FROM TO ❑Not Present [resent,Removed Prior to Sealing ElOther <br /> If not known,indicate estimated formation log from nearby well or boring. Type ...].�d '""y r_a r.-, . <br /> • 0 / •}s.METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> '�VV.+� r. No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> sing 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 well? ❑Yes [ r ° TN# <br /> GROUTING MATERIAL(S) <br /> 11 6 G <br /> Grouting Material�O�ri� c� ,, n,frdm to �9 J5" a ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes 0No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION �'` <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 Well Drilling Co,.Tnc. 1691 <br /> Licensee Business Name License or Registration No. <br /> /r/ ,*''''' '/ <br /> J ;;efltveSignaturee /J. - ao -c,,,R0 <br /> Certified Rep.No. Date <br /> " 380883 X1—'�'1\t <br /> LOCAL COPY Name of Person Sealing Well or Boring/ <br /> / <br /> HE-01434-17 ID#53159 .111 11r198 <br />