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�.+�- <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota W�:II an�i Boring }„� ������ <br /> �o��,y Name WELL AND BORING SEALING RECORD M��r','e�o a°u��q�e weu rvo. -- <br /> Minnesota Statutes,Cha ter 1031 or W-series No. <br /> P lLeave blenk il noi known) � <br /> Township a Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring ConsVuc�ed <br /> /�/ /2 <br /> , <br /> Latitude degrees__ minutes___ seconds De /"�,� <br /> GPS pth Before Sealing �"��✓' tt. Original Depth ft. <br /> LOCATION: Longitude degrees___ minutes seconds <br /> 4 AQj11FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Multiaquifer �� �n� <br /> 247b 1km�oody Ave, � WE UBORING Measured L Estimated Date Measured M <br /> �Water-Supply Well ❑Monit Well � <br /> Show exact location of well or boring Sketch map of well or boring �.Em.Bore Hole Other ft. elow ��above land surface <br /> in section grid with"X." location,showing property ❑ �— � , <br /> N + lines,roads.and buildings. CASING TYPE(S) <br /> t <br /> _ -- --_ _-_-- -- � �r �� Steel ❑Plastic �.]Tile �_!Other___ __ a <br /> :�� <br /> WELLHEAD COMPLETION <br /> : W : : ; ; ET <br /> '. � � _;_____r__ Outside: ❑Well House ❑At Grade Inside: ��.J!�Basement Offset ,:. <br /> '� , � � , 'h M�de � itless A p dUnd ❑Buried ❑Well Pit <br /> , , , , � ❑P' da te <br /> ; --�-----T-----�-----:- <br /> � � S � � <br /> ❑Well Pit �J Buried <br /> �1 Mile� ❑Other ❑Other <br /> PR lErRTYR W R'S ME/COMPANY NAME CASING(S) <br /> �7.� 4l �� . ' <br /> g Diameter�� Depth �♦` Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailinq address if different than well location address indicated above j CP+ �j �' � ❑UnknOwn <br /> _�in.fram GO to Z- •ft. ❑Yes o ;Yes No <br /> Z'SO4 ducm�dy Ave <br /> V��� M�i 55391 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 2 of 2 in.from to ft. ❑Yes U No ❑Yes ❑No ❑Unknown <br /> .+ WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � �� <br /> �f/j� i <br /> � Well owner's mailing address if different than property owner's address indicated above Screen ffom �� to +fr��(✓ ft. Open H012 frOm _ .. to ft. <br /> OBSTRUCTIONS <br /> r'Rods/Drop Pipe ❑Check Valve s 6 <br /> ( ) ❑Debris ❑Fill �jo Obstruction <br /> � Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> Type <br /> 0 Removed �Not Present ❑Other <br /> M THOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Cesing 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 /> '`�//t ML � � <br /> 2� �01 GroutingMateriaVy�/Y� ��/!��'L'�from �t7' to Z�tt. yards � bags <br /> 0 <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes �No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICA710N. <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true ta the best of my knawledge. <br /> Don Stodol.a �,Te22 Drilling co,. inc. 1541 <br /> Licensee Business ame License or Registration No. <br /> 5-15-12 <br /> C presen iv... �gnature Certified Rep.No. Date <br /> LOCAL COPY H 3 O Z V�� �� �t��� — � <br /> Name of Person Sealing Well or Boring <br /> .:. —_.-------- :. <br /> HE-01434-12 IC#140-0423 9iosR <br /> ,i <br />