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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �5 8�9? CountyName WELL AND BORING SEALING RECORD Minn'egoa�UniqueWellNo. �� Minnesota Statutes,Chapter 1037 or W-series No. (L¢ave blank i�not knownJ Township e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed '� '� ? /r��r1 �'7 , 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 Ciry of Well or Boring Location Single Aquifer ❑Multiaquifer �., �y} � W UBORING �Measured ❑Estimated Date Measured:��//''� j � , r ._.Water-Supply Well n Monit Well ' Show exact loca wn of well or boring Sketch map of weli or boring , /� in section qrid with"X" location,showing prope t i.J Env.Bore Hole � �Other_._ �C�� ft. �below .above land surface ! N f�� lines,roads,and uildi� .� ; �., o ASING TYPE(S) ``EC --;-- �--- ---� _._ . . � E�� � Steel �_]Plastic ;.�Tile []Other__,___ ______ . _�_ �� --'-'---'--- ---`-----`-- ELLHEAD COMPLETION . .,��. �� W 2 9 �� W ' ' ' ' ET d IIH G d O __;____ ,__ _�_ __;__ I Outsi e: ❑We ouse ❑At ra e Iry��: ��,c'Basement s00� � 7.M�ie �Pitless AdaptedUnit ❑Buried ` �C��iY1^O --�----�-- --;-- ---�- I ❑Buried` �r� No L ❑Well Pit S ❑Other �-1 Mile� ❑OthBf PROPERTY OWNEF'S NAME/COMPANY NAME CASING(S) Diam tgr/ t Dept`h�•^/ � Set in oversize hole? Annular space initially grouted? r e ai erent than well location address indicated above ��n.from� to�ft. ��Yes �No ❑Yes ❑No ❑Unknown ll!'t� �tl$CMVI)U [1J.1 ls Rd in.from ta ft. �]Yes U No ❑Yes ❑No ❑Unknown Qrono, l�t+T 55391 in.from to ft. ❑Yes ❑No ❑Yes �,]No !`��..Unknown WELL OWNEA'S NAME/COMPANY NAME SCREEN/OPEN HOLE �y � Well owner's mailing address if different than property owner's address indicated above SCreen ffom / /� ' to�ft. Open Hole irom to ft. OBSTRUCTIONS Rods/Drop Pipe ❑Check Vaive(s) ❑Debris ❑Fill ❑No Obstruction ��.►- //�� ^ Type of Obstructions(Describe.L E-/�/V'��. �r�� g' I vI��J_ 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 �(��? �!V M� � '�Removed �_ 1 Not Present ❑Other _.__ . METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe U Casing Pertoration/Removal _in.from to ft. ❑Perforated ❑Removed in.from to _ ft. ❑Perforated ❑Removed Type of Perforator � _..___ ❑Other_ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) r r Grouting Material/��j �.�/},�AJTfrom_�_ to��ft. yards� bags from to _ fl. 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 properry? ❑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 Drillin� Go.� Inc. _ 169I______ Contractor Business Name . License or Registration No. � �.. ' p�� i �Z(7"i17 , ��/' ...^_�� ,��._ , �_�- �. - --- .. ____— ._._._._ - ----- --- -'erti ed Representative Signature� Certified Rep.No. Date 258497 J� �t��, . LOCAL COPY H -- -- --- —-- Name of Person Sealing Well or Boring HE-01434-09 IC#140-0423 sio6a -. . . ��..,�_ ..y. : :.,. <. .,-::.. ,.�..,.. ��.� . :�.�._ ,r�. ,.�.,: - ..�_ . ... . . . :...._ .. ._ _:� ..,�•. "'--