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�WELL OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTH c Minnesota Well and Boring I„I ��A�} = County Name WELL AND BORING SEALING RECORD Menne9oa°u��q�ewe��No. �tr ` � i� Minnesota Statutes, Chapter 103I or W-series No. (Leeve blenk If nol known� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Conshucted �cio 217 23 08 '' '' '' �Z �.T' �''7 / . GPS Latitude degrees minutes seconds Depth Before Sealing ` �� ft. Original Depth_ ft. LOCATION: Longitude degrees minutes seconds UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location _. ingle Aquifer ❑Multiaquifer cn,y}f /�/� �t7EA pJ� T,d..�,3 /�,.�,�� !!7lf1 WELL/BORWG Measure� ❑Estimated Date Measured J//"'- '�!' ` .7YlU 17`i i�!}� VLG�iJ{7 .7.�37Y �- Water-Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or boring �j in section grid with"X" location,showing properry � �Env.Bore Hole ❑Other � ft. �elow �_1 above land s�rface - _ N lines,roads,and buildings. CASING TYPE(S) -'----'--- --`-- ---'-- I I � ' 4 . , , , ; �Steel U Plastic []Tile [�Other �� --'-----�--- ---`- ---�-- WELLHEAD COMPLETION ' � W ; � ; � ET ,,..:' ' ' _;-- -_;-- l.. asement Offset �� _ ,_____,___ _ �At Grade Inside: � � Outside: ❑Well House ';;� � � � � M'ie dless A p r/Unit , Buried ❑Well Pit h � , , , , , � U P� da te � :�}:> --�-----�--- --�-- --%-- 4. � . ❑Well Pit ❑Buried S ❑Other �-i nnae� � ` � f� ]Other A..vC..i�. (�/!•,..,..�.� �� P OPE OWNER'S NAM COMPANY f�1ME CASING(S) �am� tte �ernaca Diamet�r� / � Dept'h'� � Set in oversize hole? Annular space initially grouted? Property owner's mailinq address if different than well bcation address indicated above _y�in.ffom V to�R. (�Yes �No ❑Yes ❑No iJ Unknown in.from to ft. ❑Yes �J No ❑Yes ❑No ❑Unknown � a in.from to ft. []Yes ;�No j_]Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � � r Well owner's mailing address if different than property owner's address indicated above SCreen trom �� to /��G+ ft. Open Hole from to ft. �O,/BSTRUCTIONS yY Rods/Drop Pipe ❑Check Valve(s) ❑Debris (�Fill ��,.__!No Obstrudion - Type of Obstructions(Describe)/�J��=��- / _� *' �+_� _._. _ 3 GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? U/Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. �� '� � � � Type U�� Removed ��Not P esent ❑Other a METHOD USED TO 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 ��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.) a,�i<R i f�il�.uT ' j� � �— � Grouting Materi from � to ft. yards 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 o How many? � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules.Chapter 4725.The intormation contained in this report is true to the best of my knowledge. � cio�n Stodale Re21 Dri.liing Co,. Inc. I691 Licensee Business Name License or Registration No. $ /�- �.� .c � erti ied epresentative Signatu Certified Rep.No. Date 264278 `�`� � �� !..00r1L COPY H i,�/Y'� _ Name of Person Sealing Well or Boring HE-01434-10 IC#140-0423 5/o�a ±