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WELL OR BORING LOCATIONMINNESOTA <br />DEPARTMENT OF HEALTH Minnesota Well and Boring <br />WELL AND BORING SEALING RECORD Sealing No. <br />Minnesota Unique Well No. <br />or W -series No. <br />Minnesota Statutes, chapter 1031 kkem Wank e o, kwm) <br />H 380694 <br />County Name <br />ile y <br />Township Name <br />Uror <br />Township No. <br />117 <br />Range No. <br />23 <br />Section No. <br />U4 <br />Fraction (sm. -+ Ig.) <br />"L'' a �' <br />Date Sealed <br />% - - � i <br />Date Well or Boring Constructed <br />� - `� i % 3 <br />GPS LOCATION - decimal degrees (to four decimal places) <br />Latitude Longitude <br />? . <br />Depth at Time of Sealing r / ft. <br />AQUIFER(S) <br />%Single Aquifer ❑ Multiaqulfer <br />Original Depth 131 ft. <br />STATIC WATER LEVEL <br />- _ j <br />Measured Date Measured /� E]Esiimated <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />WELUBORING <br />how exabt loco ton of wet or boring ch map of well or boring <br />in section grid wish "X." location, showing property <br />t lines, ro��ds+�nd buildings. <br />N =q./ n <br />Water -Supply Well ❑ Env., Well <br />❑ Temp. Boring ❑ Other � <br />/ I <br />�7 f ft. bdfow ❑ above lard surface <br />CASING TYPES) <br />- --'r-- -`-- ---`-- / <br />- i--- - /' • • <br />Steel ❑ Plastic ❑ Tile ❑ Other <br />WELLHEAD COMPLETION <br />W_ e�Outside: <br />❑ Pltle'ss AdapterNn(t ❑ At Grade Inside: E] Basement Offset <br />'h MileWell <br />- -T 1 <br />s <br />❑ Pit Buried F1 Well House <br />Other El wait Pit <br />F-1- <br />❑ Burled <br />�1 Mlle—� <br />❑ Other <br />For temporary borings, provide additional location <br />information, a site sketch, and geology on a separate page.Diarrter <br />CASING(S) <br />In. from oept�r ft. El Yes oversizeoole7 ❑AY star space Nolttail ❑ Unknown <br />In. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Property owner's mailing address if different than well location address indicated above <br />939 Sad Willow Pass <br />in. from to ft. El Yes E] No, ❑Yes ❑ No ❑Unknown <br />(� <br />Drif LWOOd, TX 76619 <br />SCREEWOPEN/HOLE`_ <br />J / <br />Screen from / CP to 1�3 ft. Open Hole from to <br />WELL OWNER'S NAME/COMPANY NAME <br />OBSTRUCTIONS <br />*flods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />Well owner's mailing address if different than property owners address indicated above <br />Type of Obstructions (Describe) l k' - <br />Obstructions removed? es ❑ No Describe <br />PUMP <br />❑ Not Present ill Present, Removed Prior to Sealing ❑ Other <br />Type L% <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS ORFORMATION <br />FROM <br />TO <br />If not)known, indicate estimated formation fog from nearby well or boring. <br />METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />No Annular Space Exists ❑ Annular Space Grouted with Tremfe Pipe ❑ Casing Perforation/Removal <br />�I <br />Casing 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 XNo TN# <br />GROUTING MATERIAL S) <br />r p�/ <br />Grouting Material f - ' om to / � ft. yards I /� 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 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 />DUN STUDOLA WELL DRILLING C0,0 INC. 1.691 <br />Licensee Business Name License or Registration No. <br />556 <br />Certified eprese taffti Si slur ffied Rep. No. Date <br />LOCAL COPY <br />JH 380694 <br />Name of Person Sea/Ing Well or Boring <br />Ht-U14J4-1 r IUB Wlbu '" 11119R <br />min <br />