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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �C /� �� WELL OR BORWG LOCATION Sealing No. H Q+�-f � � County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Chapter 103/ or W-series No. Nec� in «aa�eb�e�k„�o,k�ow�, Township Name Township No. Range No. Section No. Fraction(sm.-»Ig.) Date Sealed Date Well or Boring Constructed 4ror�o 118 23 26 '' '' '' Q [�,�� GPS Latitude__ degrees minutes seconds Depth Before Sealing T�i _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 .�+ J1�r 7"iV iJ�1Wt8 ti�� Clccmo 55356 WELUBORING �Measur fd ❑Estimated Date Measured.��'` � Water-Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well ort�o r�j � in section grid with"X:' location,showing prQy�r�"' �..)Env.Bore Hole ❑Other � ft. �below ❑above land surface N lin . , d buildi�s. CASINGTYPE(S) --'-----"--- '--`— --'-- ., Steel �Plastic r�Tile r]Other_ � --'--- --�--- ---�-- ---`- WELLHEAD COMPLETION �� : W ; ; � : ET _ � ;__ _._�. � Outside: ��Well House I ]At Grade Inside: ❑Basement Offset ': '/'M'�" �Pitless Adapter/Unit �]Buried ❑Well Pit 1 ❑Well Pit J Buried �—i nn�ie--� i'"� �,�� Other ��Other i_..-� �. .}.. P PERTY OWNER'S NAME/COMPANY NAME CASING(S) er � Diam tef� � Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above ��n.from � to�_ft. ❑Yes �No ❑Yes ❑NO ❑Unknown in.from to ft. ❑Yes ❑No ;_J Yes ❑No �]Unknown �i � in.from to ft. (�Yes ❑No ❑Yes n No �.j Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � t !� Well owner's mailing address if different ihan properry owner's address indicated above SCreen.from �j�. to_��i+ ft. Open Hole from to ft. OBSTRUCTIONS []Rods/Drop Pipe ❑Check Valve(s) �,�Debris ��'�Fill �No Obstruct�on Type of Obstructions(Describe) 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. / // Type a.,..-� ( � rY7p ❑Removed Not Present ❑Other .___ METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists ' �Annular Space Grouted with Tremie Pipe j�Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to fl. �]Perforated (�Removed Type of Perforator h ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material f(�f�/ C_..'�� rom � , to � ft. yards__�__ bags from to ft. yards___ bags irom to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on properry? [�Yes o 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 hue to the best of my knowledge. da� Stvdola i+kll Driliing Co., Inc, 1691 Licensee Business Name License or Registration No_ ,�' _ � _�r"7 � 7 � Certified Representative Signature Certi/ied Rep.No. Date i.oc:,,�cu�v H /� _..._ �� '�,��.� 2��i.�� Name ol Person Sealing Well or Boring ' HE-01434-10 IC#140-0423 � � 5/o7a �