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� WELLOR BORING LOCA710N MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 215176 County Name WELL AND BORING SEALING RECORD Menn'ego a�Uriique Well No. H�nc�epin Minnesota Statutes,Chapter 1031 or W-series No. (Leave blank�il not'finavnl Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed Orcmo I27 �s os a�oou� p��, GPS Latitude degrees minutes seconds �/� � � LOCATION: Depth Before Sealing �r/ ft. Original Depth—��ft. Longitude degrees minutes seconds p U FER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer �VE�UBORING Measured ❑Estimated ��Water Supply Well ❑Monit.Well r Show exact location of well or boring Sketch map of well or boring in section grid with"X" �, �i location,shoWing;property Env.Bore Hole ❑Other /� ft. �below ❑above iand surface N M,�._.��,_�Ji��„�oads,'�n�j+�i�ui{E�gs.. CASING TYPE(S) � � � � -- - - - -- -- -- -- "—' Steel ❑Plastic ❑Tile ❑Other W -- - - -- - -- -- -- E WELLHEAD COMPLETION r � , , � � ` � � � � � �� Outside: ❑Well House Inside: ❑Basement Offset � �— i-- -;— —i-- . � � � � � �m'� � ❑ Pitless Adapter/Unit �Well Pit � -�-- -i-- -i-- --i-- I � � . 1 � ❑Well Pit ❑Buried S �r mee� ❑Buried PROPERTY`O+W,,�NER—'S NtAME/COMPANY NAME CASING(S) �� AFii.Wihl Diameter Depth r Set in oversize hole? Annular space initially grouted? Property owners mailing address if different than well location address indicated above /j �� in.from� to��ft. ❑Yes �No ❑Yes ❑No ❑Unknown ifl.ffOrr1 t0 ft. ❑Yes ❑ No ❑Yes ❑No ❑Unknown in.from t0 ft. ❑Yes ❑ No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE . Well owner's mailing address if different than property owner's address indicated above Screen from�t0�_ft. Open Hole from t0 ft. OBSTRUCTIONS �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction /� 3 Type of Obstructions(Describe) �/v�U�--1� /�.�/�� $�' �..f��s GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? eS ❑ NO D2SC�ibe FORMATION If not known,indicate estimated formation log from nearby well or boring PUMP C:� :�C� TYPe �� J/Y�� �' I�Removed ❑ Not Present ❑ Other 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.) Grouting Material /�,T �� rom�SL to��./ yards """' bags � from to R 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 acwrdance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. Don StActola Well Dri13�s= Co., Inc. 27172 ContractorBusiness ame �'� �'� LicenseorRegisfrationNo. _.._..--` + �� �/" j` +.�✓ �... ' or e resenta ve Signafure � Date `� � LOCALCOPY H 2151 '�;�-rY_ �.z.,�, .��..,�..�.,-, Name of Person Sealing Well oi Boring .