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i : WELL OR�OaING LOCATION MINNESOTA DEPARTMENT OF HEALTH ^^ Minnesota Well and Boring '„I ��O��C Cor'nty Name " WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. �, J Minnesota Statutes, Chapter f03� or W-series No. u�f1�'f�[��T (Loave blank If nol known) A saa4 r H Township Name Township No. Range No. Section No. Fraction(sm.—�Ig.) Date Sealed Date Well or Boring Constructed qt�og�oa�ta 118 23 3S 1�4-0003 � �- �� , GPS Latitude degrees mi�dl�� ''��sgcb�� Depth Before Sealing �� ft. Original Depth k. LOCATION: Longitude degrees minutes seconds UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and G1t�of Well or Boring Location _ Single Aquifer ❑Multiaquifer ��iyfL /�/1// 60 �ia�t LOA_ yia a0$u �L/BORING Measured �]Estimated Date Measured.a �� 7 � '� �� -- � � �J ater-Supply Well (]Monit Well . Show exact location of well or boring � � -s; Sketch map of we or boring �/ in section grid with"X:' - � location,showing property �Env.Bore Hole []Other � ft. �[y below �]above land surface N ��^�'� lines,roads,and buildings. CASINGTYPE(S) +� � � � � �, --'-----'--- --`----'-- ' At� I�Steel []Plastic ❑Tile ❑Other __ � --'--- --'--- --`-----'-- �ir �j • ELLHEAD COMPLETION W ; ; ; ; ET � "" __�___ __;__ __�__ __r__ �.'S f, Outside: �Well House ❑At Grade Inside: ❑Basement Offset 'h Mii �1� �Pitless AdaptedUnit ❑Buried ❑Well Pit --�--- --�----�-- --�-- ❑Well Pit n Buried S � ❑Other �i M�ie� �;Other PAOPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diam �� ,'}I Depth e Set in oversize hole? Annular space initially grouted? ProperTy owner's mailing address if different than well bcation address indicated above �in.from C� to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown � �� in.from to ft. ❑Yes ❑No []Yes ❑No ❑Unknown � in.from to tt. ❑Yes (-]No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE Q� � � er' er w ess b e Screen from CJ Z to � ft. Open Hole from to ft. V�� Beaver Df1$� ►�i�.• ,O�,BS,[TRUCTIONS �y�riods/Drop Pipe ❑Check Valve(s) ❑Debris [�Fill �_l No Obstruction /� n �i�Y`ti��i��• � 55391 Type of Obstructions(Describe) �N��-✓�- �r _ ¢ �u•' KY GEOLOGICAL MATERIAL COLOR HApoNEss oR FROM TO Obstructions removed? I�Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. !� f ' Q �� Type SV,` �L)n"l�� ti� �emoved ❑Not Present [�Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to _ ft. ❑Perforated ��Removed in.from to ft. ❑PeAorated []Removed Type of Perforator ..__ ['Other_ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) ,t ,? /} ,�y�� r Grouting Materiall�L/�� `'��/'_U�from_�_ to�� ft. yards� bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFPICULTIES IN SEALING Other unsealed and unused well or boring on property? �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. � Don S�odola well Dsillin� Co. ,. Inc. 1691 Licensee Business Name �-- License or Registration No. J%. ,,9,�' � ? , /�' /.i -�� Ce�ed Representative Signature Certilied Rep.No. Date I�GCkL CQ�Y H � ! O Z V� �\' ;`"";, ti ��, . .Ii�a�r_w- % Name ol Person Sealing Well or Boring HE-01434-10 IC#140-0423 �'� 5/07R