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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �..� 2 6 4 3 0 3 County Name W�LL AND BORING SEALING RECORD Mennlesoa�Unique Well No. ' Minnesota Statutes,Chapter 1031 or W-series No. (Leava blank�if no�known) Township am Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed 117 23 21 3-+(�i �� /�J <,-f P o 7 , GPS Latitude degrees minutes seconds Depth Before Sealing `�✓ � R. 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 Single Aquifer `.J Muttiaquifer I ��M� � W UBORING Measured ,'Estimated Date Measured �� Water-Supply Well ❑Monit Well � Show exact location of well or boring , -p S etch map of well or boring +� in section grid with"X" x '�c location,showing property . �Env.Bore Hole !,�Other _ �-/� ft. �below U above land surtace N � � lines,roads,and buildings. CASING TYPE(S) �: --'-- --�----`-----'-- 4 [�Steel ❑Plastic ❑Tile [I Other � � --'--- --r-----`-- ---'-- WELLHEAD COMPLETION � � W : ; : ; ET - � � � � Outside: �Well House �At Grade Inside: �Basement Offset �. 'h Mile �wQ�e �Pitless Adapter/Unit ❑Buried [�Well Pit -- - I 1��'i ❑Buried 1 ]Well Pit S ❑Other .. �t Mile—� ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) � Diarpete�� ^ � Dep� �� Set in oversize hole? Annular space initially grouted? Proper y owners mailing a ress if i erent ihan well location address indicated above W � in.from 4� to ft. ❑Yes �No ❑Yes ❑No ❑Unknown 475 i'IdLA�r Ot� Ste 445 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown Mirmeppolia, I�1 55405 in.from______._ to ft. ❑Yes ❑No ;J Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOIE � I� f Well owner's mailing address it ditterent ihan properry owner's address indicated above SCfeen ffom � 1 to '�' ft. Open Hole from to ft. OBSTRUCTIONS �Ftods/Drop Pipe ❑Check Valve(s) ,__]Debris �J Fill ❑No Obstruction Type of Obstructions(Describe) �N/��J` i =� 4` �U �y� ""��--- GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructians removed? Yes ❑No Describe � FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. �-+� Type S U n' PU M A �-�" �'�` � f'�f �temoved ❑Not Present ❑Other `-�� METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: [�o Annular Space Exists ❑Annular Space Grouted with hemie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed . in.from to ft. U Perforated [Removed Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material ��A�C_�/�=�jr�� to / � h 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 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. �bn Stodola T�e].1 Drilling Co,. Inc. 2691 Licensee Business me License or Registration No. � � ��j ''7 '�G'S.� iJ / rr' ertified epresen ative Sigrial e Certified Rep.No. Date ��,�:;j��.�� H 264303 ��m- � .�`'�.��_�.�,- Name ol Person Sealing Well or Boring HE-01434-10 IC#140-0423 � 5/a�a �. , ��.-.�_—i_ _.. . ..__ ... . ,�_ . . .. ---------- -�...- --='-'._, :.. .��..::.�..,.. _ . .. . ,... . ....._ _,...-�--.,, . . . . ...:.... . ... �,.. _ �-.::.. ....._.