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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I ��Q�Q� <br /> WELL AND BORING SEALING RECORD Minnleso a�Unique WeII No. V �' <br /> Counry Name - <br /> Minnesota Statutes,Cha ter 1031 or W-series No. <br /> HOIIIIAj��A p ,�ea�e o�a�k���o�k�ow�, <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> /. /< /, !7!� V <br /> ► <br /> �� GPS Latitude degrees minutes seconds Depth Before Sealing �� ft. Original Depih ft. <br /> LOCATION: Longitude degrees minutes__ seconds p UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City ot Well or Boring Location . Single Aquifer ❑Multiaquifer � �y�L /� <br /> 1 08 /r1.eVv �hi.! �� OrO,�OI- �• WEWBORING �Measured [�Estimated Date Measured,.'r�fJ = �✓/�� <br /> bii j <br /> Water-Supply Well ❑Monit.Well 1 <br /> - Show exact location of well or boring Sketch map of well or boring /�,a <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other v`� ft. �below ❑above land surface <br /> N ,� lines,roads,and buildings. CASING TYPE(S) <br /> k <br /> � --'--- --'--- --`-- --'— �. <br /> � � � � � <br /> Steel ❑Plastic ❑Tile ❑Other <br /> �' --'----i--- ---`-- --`-- � WELLHEAD COMPLET�ON <br /> { <br /> � W ; ; ; : ET <br /> :: � � � � � • ,_a� Outside: ❑Well House �]At Grade Inside: j�Basement Offset �� <br /> — ----- --- ----- -- �7 <br /> �� � � � � e '� itless A p dUnrt ❑ uned . ell Pd <br /> h <br /> �P� da te ' B �W <br /> . --.----r-- --�----.- 1 :: <br /> ❑Buried <br /> � � S � � <br /> �]Well Pit []Other <br /> �-1 Mile-� :"'1(��r.,.a, ....11_.F3.-.ca...� i�� ��OthOf <br /> _.r- � ]1 <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> t�ark D Wf ili��� Dia eJef /`�1 Depth � Set in oversize hole? Annular space initially grouted? <br /> .Properry owner's mailing address if diflerent than well location address indicated above �in.from_ ( to �� ft. ❑Yes �No ❑Yes [,No ❑Unknown <br /> I QZ � JWb S�r=e�t St� 1 in.from to ft. ❑Yes ❑No �]Yes ❑No ❑Unknown <br /> Chaaka,. I�i.. 55316 <br /> 61 i�251�97g0 _in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE t � <br /> Well owner's mailing address if diflerent than property owner's address indicated above Screen ffom �� to /O� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> [�ods/Drop Pipe [_j Check Valve(s) ❑Debris []Fill ❑No Obstruction <br /> Type of Obstructions(Describe)�N��� / .L�� ; /�u��/` <br /> ' GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? s ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated forma[ion log from nearby well or boring. �Ut2 �m� <br /> � TYPe � <br /> �� � � <br /> �Removed �]Not Present ❑Other <br /> JMETHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists �Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to_ ft. I�Perforated �]Removed <br /> in.(rom to _ft. �]Perforated []Removed <br /> Type of Perforator <br /> [j Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bent�nite=50 Ibs.) <br /> � l �i�C� ► <br /> Grouting Material/`�'��� ��`�r^�Tr6m Q to ��ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS � <br /> s <br /> REMARKS,SOUHCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes � o 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 <br /> is true to the best of my knowledge. �" <br /> DON STODOI.� tlELI. D8ILL2NGC0.. I�iC.. 1691 <br /> Licensee Business Name � License or Reg�stration No. <br /> ; �� � ' Sss .� �o. O�, � <br /> Ce i r �tative 3/gnature ,i'� Certilied Rep.N¢ � Date <br /> _rC^.�COrY H i.�V�V� \/`��.-� `._��/�;�trr'✓a,�ly1 <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-10 IC#140-0423 � . .. Sio�R �� <br />� _ _._ _. ._ ._. _ _ ... __. . _ .. . . . ._. . _ . _ . _.. ___ .. . . . .. .. � _. ___ . ._---- - <br />