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_ - ---- MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring C C(��Q WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Menn'eso a�Unique Well No. H �j V�J 0 County Name Minnesota Statutes, Chapter 1031 °edW serieskNo. Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Dafe Well or Boring Constructed ,, ,, 9 �� . GPS Latitude degrees minutes seconds Depth Before Sealing� 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 �ingle Aquifer ❑Multiaquifer �/ai�/ /�y�� = p W WBORING �Measured ❑Estimated Date Measured�� Y � nd � 3 ' Water-Supply Well ❑Monit Well � Show exact location of well or boring Sketch map of well or boring in section grid with"X" location,showing property L�Env.Bore Hole [.;Other � U ft. �below ❑above land surface N lines,roads,and buildings. CASING TYPE(S) i --'----`-- ---`— --'-- �'..r..�.. ��.. � � � j �. �� Steel ❑Plastic ❑Tile ❑Other � � � •�� ' --'--- � --`-- ---`-- � �� WELLHEAD COMPLETION �� —i--- - i � , � , w ; ; ; : ET ._._- - " , __�____,__ _� __�_ Outside: ❑Well House �_j At Grade Inside• ❑Basement Offset � 'hI Mile ❑Pitless Adapter/Unit ��Buried ❑Well Pit ---- - I ❑Buried : L ❑Well Pit ' S ❑Other n �1 Mile� ❑Othef ��r�t="u �xT frZ PFOPERTY OWNER'S NAME/COMPANY NAME CASING(S) Dia ep� i Depth I Set in oversize hole? Annular space initially grouted? Property owner's mailing addres different ihan well location address indicated above � � �Z I�I � f� �� ❑Unknown in.from to ft. Yes No _ Yes No 565 Big Woods �1� in,from to ft. ❑Yes [�No ❑Yes ��No I]Unknown Chsnhass�n, �T 55317 in.from to ft. �_�Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � � I ; Well owner's mailing address if different than property owrer's address indicated above Screen trom_ 1,7�_ro�ft. Open Hole from to ft. � ` OBSTRUCTIONS �Rods/Drop Pipe ❑Check Valve(s) I']Debris ❑Fill r]No Obstruction Type of Obstructions(Describe)..L./v��` �.�� " �Gf/��.� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed?�Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. � �/ - -Jf�� Type�CJI� �vmD f" � '�� '^ emoved �.�!Not Present ❑Other a METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CAS�NGS,OR CASING AND BORE HQLE: � No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to R. ❑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.) ,�!-�V,�y► r •��-f Grouting Material/�/L/5" �-""„��T from�__ to��_"__ ft.______. yards �� _ bags _ from to ft. yards bags i. __ 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? ��-J Yes�No How many?_ _ LICENSED OR RF_GISTERED 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. > I� stodola Weli ncilii�Co,. inc_._ 1691 � Contractor� sin ss Name .-� � � License or Registration No. ` `' �"� `� 1 -' � �`'—� � " `-' -t' -- -- C ified Representative Signature l Certified Rep.No. Date Name of Person Sealin Well or Borin �� - " 256098 ��-- � , LOCAL COPY �,.—� ' j �""ipW�---�-�— ---—._ 9 9 HE-01434-09 IC#140-0423 . s/osa