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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 5 8 4 0 6 County Name WELL AND BORING SEALING RECORD Mennlego a�Unique Well No. Minnesota Statutes,Cha ter 1031 or W-series No. H.IIII@ j��11 P (Leave blank il not known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed � rono 117N 3 '' '' '� c'a R��r� l�� ► GPS Latitude__ degrees minutes seconds Depth Before Sealing �� ft. Original Depth_ ft. LOCATION: Longitude degrees _ minutes___ seconds UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City o1 Well or Boring Location Single Aquifer U Multiaquifer � �^,�„/ �� WELL/BORING __:Measured Estimated Date Measure ��P� 2545 Water-Supply Well �j Monit.Well Show exact location of well or boring Sketc map of well or oring � �Env.Bore Hole ❑Other ____ �� I ft.�]below ❑above land surface in section grid with"X' SS.391 location,showing prop rty — N lines,roads,and buildi g# CASWGTYPE(S) ��, Steel �__1 Plastic �. �Tile ;�Other __ � --'-- --''--- '--`— --`-- 0� ��1 � LLHEAD COMPLETION � W � � � ---� E T � �� -� � � � _; r �� Outside: ❑Well House ��At Grade Inside: �Basement Offset � '/z Mile `� [J Pitless Adapter/Unit Buried ❑Well Pit ------ ------ ---------=- 1 � ❑Buried �Well Pit S ❑Other �1 Mile� �� !�Othef PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diameter t Depth t Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than we cation address!ndicated above � �in.from � to��_ft. ❑Yes �J No ❑Yes ❑No ❑Unknown 952�471�7p�� in.from to ft. ❑Yes I�No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE / Well owner's mailing address if different than properry owr.er's address indicated above Screen�rom_�__to�_�� ft. Open Hole from � to______ ft. OBSTRUCTIONS � Rods/Drop Pipe ❑Check Valve(s) j�Debris �]Fill �.�No Obstruction > c Type af Obstructions(Describe)�1(l��/�,_��Q� �- � /' �___..._. _ � A�OLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bshuctions removed? Yes '—,,No Describe � FORMATION PUMP If not nown,indicate estimated formation log from nearby well or boring. - e . r TYPe--- — ; � ❑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 ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Pertorated [i Removed Type of Perforator ❑Other _ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) � r Grouting Material�� C �,4�UJfom�_ to� ft. __ yards� bags [J 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 property7 ❑Yes�No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION r 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. k ! D01�1 STODOLA T�TELL DRILLING C0. , INC._�1_6_��___ Contractor Business me License or Reg�stration No. � 'i . .� „( .r. J / � / �_----.. rtili Representative Signature".. Certilied Rep.No. Date " 2 5 8 4 0� `�rr�-.- �-�--`-_��'.�-�`_.° LOCAL COPY Name of Person Sealing Well or Boring � HE-01434-09 IC#140-0423 tl' s/osR