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wELL OR BORING LOCAT1oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„� �/����� <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. L <br /> F� in Minnesota Statutes.Chapter 1031 or W-series No. <br /> c�ew ae�n�a ww�+q <br /> Township Name Township No. Range No. Section No. Fradion(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> Oror� 11 23 f� 2 -0033 �,. �,. �,. �.. <br /> GPS �ntude degrees minutes seconds <br /> LOCATION: Depth Before Sealing , tt. Original Depth �� ' ft. <br /> Longitude degrees minutes seconds A UIFER(S) STATIC WATER LEVEL , <br /> Numerical Street Address or Fire Number and City oi Well or Boring Location Single Aquiter °�Multiaquifer <br /> E L/BORING � �Measured ❑Estimated <br /> Water Supply Well ❑Monit.Well t <br /> Show exact location of well or boring Sketch map ot well or boring <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other ��",,,�ft. below ❑above land surface <br /> N ---Jiaes,sea�e; uildings. <br /> [ CASING TYPE(S) <br /> F-_--w Steel ❑Plastic ❑Tile ❑Other <br /> - W "�- - -- - -- --�-- E �~� WELLHEADCOMPLETION <br /> � , � ;�t�'r , Outside: ❑Welt House Inside: ❑Basement Oifset <br /> —�- ---- -;-- --i-- <br /> - � �^'� �Pitless AdaptedUnit ❑Well Pit <br /> ' --�- -i-- -i-- --�— � . <br /> ❑Well Pit ❑Buried <br /> z S <br /> ��nw--�. . ..._ �._c...,..,-.� _ <br /> ❑Buried <br /> ;; PROPERT�Y+OtWNER'S NAME/COAMCPAN—Y/NAME�t �y CASING(S) <br /> J� L1�31�1$ 7 J2�'i��cJ733 Dia� Depth � Set in oversize hole? Annular space initialty grouted? <br /> Properry owner's mailing address if different than well location address indicated above f� �} ,...,/ <br /> in.from� t0�.L ft. ❑Yes �(No ❑Yes ❑No ❑Unknown <br /> I� <br /> in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.f�Of1l to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> ,� Well owner's mailing address if different than property owner's address indicated above Screen from�_t0�_ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe),�f�,/���.���a.��� <br /> . � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 0S ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Type <br /> � Removed ❑ Not Pres t ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � �o Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material���(��11F'�[J! from��to�—tt. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS - � <br /> �� REMARKS,SOURCE OF DATA,DIFFICULI'IES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Uon Stodola �li Drillin� CA, Inc, 27172 <br /> Contractor Business ame I' License or Registration No. <br /> :.� : <br /> � / <br /> -' /� ..� �/ .�. 4� <br /> d ese �ve igna(urr Date <br /> LOCAL COPY H G..G.LJ�L� �f'�i.-� . .'��� ._���-..,...,�. <br /> Name o/Person Sealing Well or Boring . <br />