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-- - -- MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 301273 ,� <br /> WELL OR BORING LOCATION Sealing No. H <br /> �o���Y Na�,e — WELL AND BORING SEALING RECORD Minnesota Unique Weil No. <br /> Minnesota Statutes,Cha ter 1031 or W-series No. <br /> P leava blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed <br /> �3 f <br /> _ , <br /> GPS Latitude _ degrees_ __ minutes__. seconds Depth Before Sealing � ft. Original Depth ft. <br /> �---- <br /> LOCATION: Longitude_ _ _ degrees ___ minutes_ _ seconds A �FER(S) STA71C WATER LEVEL <br /> Numerical Street Address or Fire Number aAnd�City of Well or Boring Location �ingle Aquifer �]Multiaquifer � �nn.y�� �(��,/ � <br /> 4156 Ai�h�rood Rd, L�Cax} 5536�+ WELUBORING �Measured Estimated Date Measured___('Jl1 IC ►71 _ : <br /> �Water-Supply Well ❑Monit.Well • t <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X." location,showing property .Env.Bore Hole ❑Other ___�� ft �below j�_',above land surface '. <br /> ' lines,roads,and buildirr11pps. � .s <br /> N � � �� CASING TYPE(S) ". <br /> .--��+.r-a <br /> _ <br /> --'----'------`—- � ' ' <br /> Steel ❑Plastic ❑Tile ❑Other <br /> - ,--- --�--- ---`-- ---'-- � ��,� WELLHEAD COMPLETION <br /> . W ; : : ET ,� �� <br /> � � � � Outside: [J Well House ❑At Grade Inside: ❑BasemeM Offset - <br /> 'h nniie �� ��itless Adapter/Unit ❑Buried ❑Well Pit _ <br /> � , � � ; <br /> --�--- --�-- ---�----*— � �� <br /> ❑Buried <br /> S ❑Well Pit <br /> ❑Other <br /> �i Mile—� ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mai ing a ress if diHerent than well location address indicated above �� �— <br /> �in.from � to�j_L ft. ❑Yes [�o i�'Yes ❑No ❑Unknown <br /> __in.from to ft. ._'�,Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. �Yes ❑No ❑Yes ❑No ❑Unknown <br /> i <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � <br /> Well owner s mailing address It diNerent!han property owner's address indicated above Screen from �J�to��ft. Open Hole ffom to ft. <br /> OBSTRUCTIONS <br /> �Rods,'Drop Pipe ❑Check Valve(s) [_�Debris ��Fill ._No Obstruction <br /> YP ( 1� �� �. <br /> T e of Obstructions Describe . /"_L./': .4._1,�� ___ . _ .. _ � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es '��'No Describe <br /> FORMATION -- <br /> PUMP t <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> (� p Type <br /> drift V OS ❑Removed �Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated if�l Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator____ _____ __ <br /> F„ <br /> �1 Other <br /> � <br /> GROU7ING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite=50 Ibs.) <br /> �l M� ♦ c � <br /> Grouting Material�/rl��1/�C�� from Q to �J ft. yards� bags <br /> from to _ ft. yards bags <br /> _ from to � ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes�No How many?___, <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report - <br /> is true to the best of my knowledge. <br /> Don Stodo2a Well �ri�Ilir�g CoT. Inc. 2692 <br /> Licensee Business Name License or Regishation No. <br /> -�;�,��'��—`_ 1-1fr12 <br /> i R p e�en ative Signature-� Certified Rep.No. Date <br /> 301273 '�' �t°�� <br /> LOCALCOPY H __ _ <br /> -------- — <br /> Name of Person Sealing Well or Boring <br /> HE-01434-12 IC#140-0423 siosR <br />