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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring � � � � � WELL OR BORW� LOCATION Sealing No. H .J �� v,� +,' r�„� County Name �`' WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes, Cha ter 103i or W-series No. Henrae� �n P ��a�P e�a��,�o,k�ow�, Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed �r�� 117 G3 li� «� *vm.a� �� I /r_ � ( GPS LOCATION-decimal degrees(to four decimal places) ' Depth Betore Sealing_.__�� ft. Original Dep[h ft ,. Latitude _ __,____ �ongitude __ - - --- AOUIFER(S) STATIC WATER LEVEL Numericai Sireet Address or Fire Number and City of Well or Boring Location . Singte Aquifer � J�Multiaquifer /�n � WELUBORING �easured ❑Estimated Date Measured,��/��}F V/'!r ' 3445 �'it;h Laisa� �rono 55356 f�jyater-Su � We�� - �,` ppy [j Monit.Well f, � F �� Show exact location of well or boring Sketch map of well or boring ��., ,�/ in section grid with"X:' location,showing property � �Env.Bore Hole n Other_ .. ft. �9 below �.]above land surface � lines,roads,�and b ildings. N �`,�'�. �ASINGTYPE(S) � -- --------- --- -- - -- � �! '��Steel �_ J Plastic ,�Tile �_]Other--- ' ' ` "'` ELLHEAD COMPLETION `N ; ; ; � E O"'1G W - �i � __;____;___ _ :_ ___�_ T Outside: �_�;Well House �,_j At Grade Inside: ��_'Basement Offset ; � _ 'k Mile �itless AdapteriUnit LJ Buried . ;Well Pit _ ; ; ; ; 1 �_� � -- --.-- --�--- --�-- ---:-- ; � � � _j Buried S ' ❑Well Pit [l Other_ �1 Mlle-� ❑Oth2f _ PROP.fE7R�TY OWNER'S NAME/COMPANY NAME CASING(S) ��1R� Baden Diame er � Depth ♦ Set in oversize hole? Annular space initially grouted? Properry owner's mailing address if different ihan well localion address indicated above �, �R ,> �_in.from V to1�pL_ft. '�,Yes ��IVo ❑Yes ❑No (J Unknown _in.from to ft _!Yes �,_;;No ['�,Yes ❑No ❑Unknown in.from to ft. ❑Yes ��:No j_'I Yes ❑No �]Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � r � `' � Well owner's mailing address it ditferent than property owner's address indicaled above SCreen from�.!�_�_ _�o�Q__,�_ft. Open Hole ffom______ to .__fL � OBSTRUCTIONS � 1 Rods/Drop Pipe ❑Check Vaive(s) f_�Debris I Fill �TJo Obstruction �°� Type of Obstructions(Describe)___ � GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes [!No Describe_ FORMATION PUMP If not 'nown,.indicate estimated formation log from nearby well or boring. ?- C.> IC...> TYPe-- - - --- .--- �` _�;Removed �Jot Present f]Other___ METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �Jo Annular Space Exisis � _�Annular Space Grouted with Tremie Pipe �_I Casing Perforation/Removal in.from to ____.ft. j_i Perforated ,'.j Removed _in.from _ to__ ft. ❑Perforated �,. J Removed Type o�Perforator ,�. �----- - ----- VARIANCE Was a variance granted from the MDH for this well? _�Yes No TNtk GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) / � f Grouting Material�✓FR/ ��I��{�om � to��fl._ yards_ (� bags f _ ____ 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? j li 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 of my knowledge. L�on Stodola t�le1l Drillin� Co,. Inc. 1f�91 Licensee Business Nam {' - License or Registration No ..- r^ � _. _�_,_�;_..,;�';':;. ;,. �'_ � �- ,�r Co1`ti6C ffepreSentative Sgnalure " Certified Rep.No. Date : - S/ � . / � LOCAL COPY H �y �`�' ��V 9 9 .�'�-r�... l✓ "'"'—�Y�LSSY\� — � Name of Person Sealin Well or Borin i '� HE-01434-14 IC#140-0423 5n3R