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�� -- - WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring � ��(�(�� County Name — WELL AND BORING SEALING RECORD Mennlego a�Unique Well No. "�� Minnesota Statutes,Cha/�ter 1031 or W-series No. �� r .LeTva blank�if no�kn wn) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Orono lI7 2. 05 9s :�E ��3 S�P � GPS Latitude degrees . minutes seconds Depth Before Sealing �� ft. Original Depth ft. LOCATION: Longitude degrees minutes seconds qxp�IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location i ASingle Aquifer [j Multiaquifer _ �1�f,. h�/ 3� P� Ot� �t� 5 5 3 5 6 W�,/ELL/BORING �Measured '_ 1 Estimated Date Measured_�/��/+rt 'JM ',� ,�wYUater-Supply Well ❑Monit.Well � � ` Show exact location of well or boring Sketch map ot well or boring -- � �/ ❑above land surface J in section grid with"X." location,showing property -_�:Env.Bore Hole ❑Other _ .____,_______. ft. ��^below N ss lines,roa�s, tlwldings. CASING TYPE(S) �� --'----'-----`-- ---'- -- �;�teel ❑Plastic �Tile ;�Other e �� -''-----.-" '-'`-' '-'`" WELLHEAD COMPLETION '�� .'� W _ �_ _ � � i E T � utside �_i Well House ❑At Grade Inside: �Basement Offset O ' : --�---- -- .-- ' �� I'-Mlle � �� '-1 PitlessAdapter/Unit ❑Buried ❑Well Pit � , � i --�----;--- --%— - - I R�� ❑Buried ; � 1 �VJell Pit S ❑Other �-1 Mile� L��the� PBQPF�jY QyJN. E�'S_N_�E!COMPANV NAME CASING(S) t�l l� I��c Diamete�/ � DepthI� � Set in oversize hole? Annular space initially grouted? Property owner�s mailing address it dittereni than well location address indicated above � �p !�/' h. [�Yes �0 �_�J Yes ❑NO ❑UnknOwn in.from to � in.from to ft. ❑Yes LJ No U Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No 'Lj Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE /�/�t (� � Well owner's mailing address if diflerent than property owner's address indicated above SCfeen from j L`� to v� ft. Open Hole from _to_ ft. � OBSTRUCTIONS ' � ❑Rods/Drop Pipe �`]Check Valve(s) I_ ebris ❑Fill ❑No Obstruction Type of Obstructions(Describe)_ 4-�=�T___ GEOLOGICAL MATERIAL COLOR HARDNESS OR pROM TO Obstructions removed? '�Yes r�No Describe C-�T �.:�G '�' ��` �� FORMATION -- PUMP If not known,indicate estimated formation log from nearby well or boring. � TYPe-- -- --- drift ��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 Pertorator_ ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) - n�! T ♦ � GroutingMaterial /�'L/�r�l C�I��/1 trom �O to �� ft. yards_� bags from to R. 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 property? ❑Yes �o 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 ol my knowledge. Don Stodolu t�ll Thcilling Co,. r�. �s�i Licensee Business Name License or Registration No. f J f/. '. �/� � T27��1 i e resentative Signa"ture Certiiied Rep.No. Date 299064 J� �t°`�" , �` LOCALCOPY H — � — - ---—._._._ -- --- Name of Person Sealing Well or Boring +'; HE-01434-12 IC#140-0423 - si09R