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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H„� `) f ` q <br /> WELL AND BORING SEALING RECORD Sealing No. i ,� <br /> County Name Minnesota Unique Well NO. <br /> Minnesota Statutes,chapter 1031 or W-series No. <br /> it EisitiEFIA (Leave blank if nol known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) Date Sealed Date Well or Boring Constructed <br /> ORO > 117 2: 07 SE'SESE ''° 1/26/23 <br /> GPS LOCATION— decimal degrees(to four decimal places) <br /> 145 <br /> Depth at Time of Sealing ft. Original Depth ft. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ®Single Aquifer ❑Multiaquifer / ,. <br /> Measured Date Measured 1 12 0/2 <br /> 4 U U&T O £ uV , live WELLBORING ❑Estimated <br /> ie A Water-Supply Well ❑Env.Well <br /> Show exact location of well or borirkiki 553 f;fijetch ma of wel r boring <br /> in section grid with"X" location,sh ing i'operty ❑Temp.Boring ❑Other 71 ft. X below ❑above land surface <br /> lines oads, u ings. <br /> N `� CASING TYPE(S) <br /> !, r Steel ❑Plastic ❑Tile ❑Other <br /> ------ ` ` WELLHEAD COMPLETION <br /> W E <br /> T ",,a4 t Outside: A Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> Mile ❑Well Pit ❑Buried ❑Well House <br /> _ ❑Other E]Well Pit <br /> S ❑Buried <br /> I 1 Mile tN <br /> ❑Other <br /> For temporary borings,provide additional location= CASING(S) <br /> information,a site sketch,and geology on a separate pag Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME �i in.from to j ft. ❑Yes ❑No ❑Yes ❑No ]Unknown <br /> J0k EL ^�RE <br /> Property owner's mailing address if different than well locatio eddress indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEN/OPEN HOLE <br /> 137 14 <br /> WELL OWNER'S NAME/COMPANY-NAMEScreen from to ft. Open Hole from to ft. <br /> JOHN E . ORE OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above gi Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> DROP PIPE <br /> Type of Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present A Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring.t� Type S ki''i}` R S I iLk. <br /> Lit R I �`�, 1 14 5 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> 4f No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <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 No TN# <br /> GROUTING MATERIAL(S) <br /> SEAT CEMENT 1 145 13 <br /> Grouting Material from to ft. yards bags <br /> from to ft. yards bags <br /> fr�tai to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No 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 WE.rLLDAILLI 4G CO. , INC. 1691 <br /> Licensee Business Name License or Registration No. <br /> ' 1 26 f 2; <br /> /' ' <br /> d Representative Signature S Certified Rep.No. Date <br /> JERRY BARR <br /> LOCAL COPY H Q <br /> -` ,,, `, _ Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />