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.� WELL�R BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I �O� /r ('� Q dounry Wamg WELL AND BORING SEALING RECORD M nn'eso a�Unique Well No. '} �,O P °�raW-series No. C'`..,: ��j`� Tttecmepin Minnesota Statutes, Cha ter 1031 Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed 4rono 117 23 10 �� d � Z j �/ / � f� GPS Latitude degrees minutes seconds Depth Before Sealing �� , ft. Original Depth -%�/ � ft. ° LOCATION: Longitude degrees minutes seconds pQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location {�( _ Single Aquifer U Multiaquifer ,�}/y /� ,�,.,I 1270 Freach Creek Dr, OrQI� 5�3�1„-' W��ORING r }�Measured ❑Estimated Date Measured�/'/��` �r,/ ' QQ Water-Supply Well ��,MoniL Well � Show exact location of well or boring Sketch map of well or �f in section grid with"X:' locati n showin ro rt� ��Env.Bore Hoie ❑Ofher __ ___ •� ft. �below [�above land surface es,roa s, n w i gs V N X CASING TYPE(S) � —'----'-- --`-----'— � � � ' ' � � f�Steel ❑Plastic [� ❑Other -,: j , , ; ; �� Tile � , , � � � ._• --------� --- :' --';-----j-- ---;`--"""j"- � � WELLHEAD COMPLETION W : ; ; ; ET e � ` � � � ; _ I �f Outside: ;]Well House ❑At Grade Inside: ❑Basement Offset `; 'hI nniie �� J Pitless Adapter/Unit ❑Buried L Well Pit --- 1 � ❑Buried S []Well Pit i 1 Mile—� � �.]Other _ ❑Other PROP�RTXCW�N�ER' A / OMPANYNAME CASING(S) xr�ct .�"cie"�ier Diam �/ � Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different Ihan well location address indicated above � in.from d to 32�/ ft. ❑Yes �jVo ❑Yes ❑No �`'�,UnknOwn in.from to ft. ❑Yes �j No ❑Yes ❑No ',�Unknown in.from ro ft. ;]Yes U No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � / Weil owner's mailing address if different than properry owner's address indicated above Sc�een from ��to 3�2 ft. Open Hole from t0 _ ft. OBSTRUCTIONS (J Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction Type o(Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? [.]Yes []No Describe FORMATION PUMP I(not known,indicate estimated formation log from nearby well or boring. � f >. TYPe— �'' � � '�'z❑Removed �lot 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 �_j 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.) Grouting Material��i�/�N1 from_�_ 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 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 ihe best of my knowledge. Ikan Stodola t�ell Drilling Co,. I�tc. Ib91 Licensee Busin ss me License or Registration No. d: -,�� .f,� �' � �I- � � e Representative Signature Certified Rep.No. Date LOCAL COPY H .� Q ; '-�t�4J �.� ,' 4_�' —�t--�-` , �C�S_��("''�—+ Name of Person Sealing Well ar Boring . HE-01434-13 IC#140-0423 . 5n2R , -�.:.. ... . . . . . .,, . . . w...:.,- .. ,... . . . .... t .. . . . . . . .. . ,. � . . ._ ...... _,.. ......., ....