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4^�ELt OR�ORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �']��A WELL AND BORING SEALING RECORD Sealing No. � �•� Counry Name Minnesota Unique Well No. Henne�:i n Minnesota Statutes, Chapter 1031 or W-series No. (L2ave blank��I nol known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed 1�7 23 06 �� ;U� p�j , GPS Latitude degrees minutes seconds Depth Before Sea�ing f S�ji ft. Original Depth ft. LOCATION: Longitude degrees minutes seconds IFER(S) STATIC WATER LEVEL - Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquiter ❑Multiaquifer �� ^��/ 4�,J0 Bg B��e n� Or n0 . �[ LL/BORING �Measured ❑Estimated Date Measured � �� • ._��Water-Supply Well ❑Monit.Well Show exact location of well or boring � Sketch map�f well or boring in section grid with"X." location,sh ing property ��_�Env.Bore Hole ❑Other �ft.�below n above land surface N lins s,r#ads, nd buildings. CASING TYPE(S) I I I I /._ --�--- --�--- ---�---�-- s j j j � ,+ �Steel ❑Plastic [�Tile U Other ` �y4; � -.____--- ----- --------- ----- -- �__,. � WELLHEAD COMPLETION � � � , � W � ; ; ; ET � __�___ __,____�.___r__ �_ Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset �� ' ' ' ' � M [� ell Pit , , , , h iie �Pitless Adapter/Unit Buried ❑W --:-- -r-----:- ---:-- 1 S U Well Pit ❑Buried �1 Mile� ' \ ❑Oth2� ❑Other ��J-..A �r`T'/ PROPERTY OWNER'S NAME/COMPANY NAME l� CASING(S) Diame �� Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if ditterent ihan well location address indicated above �in.from � to ��ft. ❑Yes �lo ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes n No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE r E r lS(� Well owner's mailing address if different than property owner's address indicated above SCfeen from �J to ! `" ""' ft. Open Hole ffom to ft. OBSTRUCTIONS '�Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill U No Obstruction Type of Obstructions(Describe) +t-�i��,J`� - �- ' "- ¢ / V i•IN _ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ❑No Describe FORMATION PUMP If not known,indicale estimated formation log from nearby well or boring. ��/), �v M� ,/ � ,�y TYPe �"' �.. ^ T �`"'`Y `-`' ��"'�p Removed ❑Not Present ❑Other METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated [J Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) /' '�' �p � / P / Grouting Material �"'��j ��l�'�(rom_.1./ to��4�' ft. yards f � bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes No 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 GIBLL DRILLING CO. ,. INC. 159I Licensee Business Name � License or Regist�afion No. _ f/� ; �,� �8 A �� -/ r,✓ y = i epresentative Sigrret Certified Rep.No. Date z72�sa ��' __ !CCAL COPY �"{ N'l.v-- L/""`" ��`�'�'��"' Name of Person Sealing Well or Boring � HE-01434-10 IC#740-0423 5/o7R 4