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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I �O��C Q ��;y Nar� WELL AND BORING SEALING RECORD M nnle90 a�Unique Well No. 5�� � i� Minnesota Statutes, Cha ter 1031 or W-series No. P �e:,�e ma�k n�o�a�owm Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed pra�o Il 23 3 SS N� SW 2U ��C ♦ , GPS Latitude degrees___ minutes seconds Depth Before Sealing �f V fl. Original Depth ft. - LOCATION: Longitude degrees_ _ minutes seconds pUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and Ciry of Well or 8oring Location ' .,Single Aquifer ❑Multiaquifer �,M [� 21(?iJ �Qx Jt� erono 55356 �y/BOSupply Well ❑Monit.Well -Measured ❑Estimated Date Measured_J�/'Ml�� /9r Show exact location of well or boring Sketch map of well or boring � r�� in section grid with"X." location.showing property ��Em�.Bore Hole [�Other _ IL.3_._ft. �beiow ❑above land surface tN lines,roads,and buildings.\, CASING TYPE(S) :__ � . l-- �(y ; 1 � I _T �Steel ��Plastic ❑Tile ❑Other �T -----_ __ ---------- - ' --�-----�------�-- "-'�-- WELLHEAD COMPLETION , W � � , � E T __;____:__ __;___�_ I Outside: []Well House ❑At Grade Inside: �Basement OBset ffi � ' , , , M�'ie itless A p r/Unit ❑Buried [�Well Pit � ❑P� da te '; --�----T-- ---�-----�- I r',Buried ' ' 1 ❑Well Pit � ' S �-1 Mile� `!'�. ❑Other ❑Othef aa.J� PR�O+,P�E,�RTY OWNE NAM COMP NAME CASING(S) ' �1C �� Diameter , Depth r Set in oversize hole? Annular space initially grouted? � P�operry owner's mailino address if different than well location address indicated above �� �in.fram�_.___ to_��ft. ❑Yes �No '�Yes ❑No ❑Unknown � ____in.from to_ _ ____ft [i Yes [�No ❑Yes ❑No ❑Unknown in.from ro ft. ❑Yes ❑No ❑Yes ❑Na r�Unknown 5 WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE . /� � Well owner's mailing address if diNerent than property owner's address indicated above SCr2en from��to ��V ft. Open Hole from _____to_. ft. e OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill y�Jo Obstruction „ Type of Obstructions(Describe)_ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions remaved? ❑Yes ❑No Describe � FORMATION If no[known,indicate estimated formation log from nearby well or boring. PUMP �,J� CJ /1� TYPe � I Removed !�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 ❑Casing Perforation/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.) /1 /+ . r Grouting Material/Vi�/7'TC_��-�'from� t�� ft. _,_ yards� bags 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 borinr�on property? r�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. Uon Stodola WeI2 Drillin� Co., I�. 2fi91 ______ - - - ---- Licensee Business ame License or Regishation No. �' " �?/ it /� rtil epresen ative Signa r Certified Rep.No. Date _ LOCAL COPY H �O 1 Z S V `\ ""'��~��j Name of Person Sealing Well or Bo � � HE-01434-12 IC#140-0423 � j - g�agp J i