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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring n C Q�� WELL OR BORING LOCATION Sealing No. H G�)C3 '' County�Jame - WELL AND BORING SEALING RECORD Minnesota Unique Well No. t�� Minnesota Statutes,Chapter 103I or W-series No. F1p}'fM{d('1�„ (Leeve blenk i�not known) �11L�j�.i Township Name Township No. Range No. Section No. Frection(sm.�Ig.) Date Sealed Date Well or Boring Constructed oc�o ii� as 2 i-oo�:� �� 22 r��' o� Q , GPS Latitude degrees minutes___ seconds Depth Before Sealing j / / k. 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 ��ngle Aquifer [;Multiaquifer q y � WELUBORING �easured ❑Estimated Date Measured��1� f1�! � ,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 _��Env.Bore Hole ❑Other _ �ft �below ❑above land surface N �li, s`,�roada,and�b�ulld�s� �CASINGTYPE(S) ,�t ...! --'----'----'-- '-"— . '` Steel [j Plastic 1-j Tile ❑Other _ _ � --'-----�--' """`" ---`-- �� WELLHEAD COMPLETION W : ; ; ; ET ' __;_____;__ ___�_, __;__ � Outside: ��Well House ❑At Grade Inside: ❑Basement Offset �!'M'� �pitless Adapter/Unit ❑Buried ❑Well Pit . --�--- --T-- --�-- --�- ( - ❑Buried -L �Well Pit S ❑Other ��nniie--{ ❑Other PROP RTY OWNER'S NAME/COMPANY NAME CASING(S) ��rt Aiiller Dia tgr i / Depth � Set in oversize hole? Annular space initially grouted? - Property owner's mailing adtlress i(different than well locaiion address indicated above �_in.ifom__�_ to��R �]Yes ��o 'i=;Yes �'No ' '�Unknown 3405 Forrlha�n Cautt � � St tf[7tiilrily� Mt�T 55421 in.fram to R �]Yes ❑No �Yes ❑No �_,�Unknown __in.from_ to ft. ❑Yes ❑No ❑Yes �_;No I]Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r /1 � Well owner's mailing adtlress if different than property owner's address indicated above SCfeen ffom_��to / /c..' ft. Open HOIe ffOm__ to fl. I / / OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) _'�,Debris �,r j Fill ��No Obstruction a Type of Obstructions(Describe)__ ____________________ � GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes �J No Describe FORMATION PUMP x If not known,indicate estimated formation log from nearby well or boring. - - � / TYPe— ---- ��"� � [�Removed �j Not Present ❑Other / -- - � METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: 'j No Annular Space Exists [1 Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from __to ft. ❑Perforated ❑Removed in.from to _ ft. ❑Perforated �Removed Type of Perforator ___ __ _ ___ ❑O[her GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �r / � Grouting Materi��Q�!L��E.C�/fromr�L__ to�_1� ft. yards_��_ bags 5 _____ _____ from_________ to ___ ft. 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 � ;No 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 true to the best of my knowledge. Don Stodola Well Drilling Co., Inr. 1691 , ---- --- -- - :: Contractor Business Name License or Registration No. , . ; :' . i% ,...� �/ " ' �..�~-c�J �G l 3 , _ �.- " �._C,� Representative Sig ure Certified Rep.No. Date LOCAL COPY H 5�4 4 7 � � ��v�v 2 Name of Person Sealing WeH or Boring HE-01434-09 IC#140-0423 s/osa