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. ._ . ' MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �(.�c O O WELL OR BORING LOCATION Sealing No. H ;,,) J County Name WELL AND BORING!SEALING RECORD Minnesota Unique Well No. Minnesota Statut�s,Chapter 1031 or W-series No. . (Leave Olank�i�no�knownJ Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date.ealed Date Well or Boring Constructed ii� 2� a� �� 9 � r.� � GPS Latitude __ degrees minutes seconds Dept Before Sealing C:(/ ft. Original Depth_ ft. }; LOCATION: Longitude degrees minutes _ seconds AQUI ER(S) STATIC WATER LEVEL - Numerical Street Address or Fire Number and City of Well or Boring Location ,_�.Si gle Aquifer ❑Multiaquifer ��,� �fa r WELWBORING 'Measured �J Estimated Date Measured�� �.Water-Supply Well [,'�Monit.Well � Show exact location of well or boring Sketch map of well or boring -- �j� �/ in section grid with"X:' location,showing property _.Ern.Bore Hole ❑Other ft/�l�'�below ;�above land surface lines,roads,and buildings. N CASING TYPE(S) ' >. �.rCS'C%'� .�' . � � � � :_ __'_____'___ "'`_ ___'" �. _ .. . 'Steel ,-_j Plastic �.I Tile L]Other__.. _ --'--- --'--- --'`"'---`-' WELLHEAD COMPLETION W ; � ; � ET ., __� ; � r Outsipe: ❑Well House ❑At Grade Inside: ❑Basement Offset �� I U Pitless Adapter/Unit ❑Buried ❑Weil Pit '- -- -- �_M.. ❑Buried S ` �Well Pit ❑Other � i Mile� �� y�� ❑Other Y PROP�[��t TY O NER'g7�[y A E/COMPANY NAME CASING(S) `av�� `c�'�n Diam tgrf t Depth � Set in oversize hole? Annular space initially grouted? Properry owner's mailing address it di(ferent than well location address indicated above < �f� in.from � to L.J�--� ft. ❑Yes �No ��Yes ❑No ❑Unknown in.from to ft. ❑Yes _,No ❑Yes [f No ❑Unknown .in.from to ft. ❑Yes ❑No ❑Yes ❑No � ,,.Unknown WELL OWNER'S NAME/COMPANY NAME SCRE N/OPEN HOLE � � � Well owner's mailing address if different ihan property owrer's address indicated above SCree ffom � to �`� ft. Open Hole ffom to_. _ft. O ST UCTIONS � ]Ro s/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obsfruction Type obstructions(Describe)�N/V'6��' ��rf�`� 4� T�v� `�%� J�� _ GEOLOGICAL MATERIAL COLOR HARDNESS oH FROM TO Obstr tions removed? �Yes ❑No Describe FORMATION If not known,indicate estimated formation log from nearby wetl or boring. PUMP 1�/ Type ��T U/� � ��'J"' '--� �� f Re oved f_�Not Present ❑Other __,. e � METH D USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: o nnular Space Exists �r;Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from ._to ft.' ❑Perforated ❑Removed �` _in.from to _ ft. ❑Perforated []Removed Ty e of Perforator x. ❑OTh r GROU ING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouti Material��-�jC.��I/ ��om � , to ��' ,ft. yards C�_ bags from _ to ft. yards _ bags from to ft. _ yards _ bags � OTHE WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other nsealed and unused well or boring on property? ❑Yes �� No How many? __ - LICEN ED OR REGISTERED CONTRACTOR CERTIFICATION This w II or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true tlo the best of my knowledge. Dac� Stodola Well Drilling Co., Inc. 2691 � Contr ctor Busine Name �� License or Registration No. ;� ��r� .'•.,.� '� �, , '��: .�-' !'=� :�, — . e i d�Representative S' ature Certilied Rep.No. Date f - '. . ,,,,.._.. � LOCAL COPY H 2 5 8 5 0 0 � ��— /'�r ��r�,/�,�/Y1� Nam of Person Sealing Well or Boring HE-01434-09 IC#140-0423 � � � s/osa ' rt�,��i� �