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v <br /> i <br /> WELL OR BORfNG LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I,,,' <br /> County Name <br /> WELL AND BORING SEALING RECORD Menn'egoNa Unique Well No. <br /> �p�� Minnesota Statutes,Chapter 1031 or W-series No. <br /> �Le�ve blank il nol knowii) <br /> Township Name Township No. Range Na Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> Oronc3 11� 23 26 1-0011 ' Z� tl L�, Q `. <br /> � , �� � <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing /✓� ft. Original Depth �„J ft. <br /> Longitude degrees minutes seconds pp���FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Weil or Boring Location �Q�6ingfe Aquifer ❑Multiaquifer <br /> 1075 Knoll i�r�ar Rd, f3rc�no 55� �UBORING �uleasured ❑Estimated <br /> Water Supply Welt ❑Monit.Well � <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" location,showing property ❑Em.Bore Hole ❑Other � ft. [�ielow ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> ��� �teel ❑Plastic ❑Tile ❑Other <br /> W -�- -�-- -�-- --�- E 9 �� ,-,�� WELLHEADCOMPLETION <br /> � � � � ,,�������� �� putside: Well House Inside: <br /> � -y� ❑ ❑Basement Ottset <br /> -;-- � -;-- --i-- �;� V <br /> �^��� '! � �"�� [�Pitless AdapterlUnit ❑Well Pit <br /> � � -i-- --�-- � � �� � <br /> T ❑Well Pit ❑Buried <br /> S <br /> �-r^"�°—�' i e�' ❑ Buried <br /> '` <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diam �, Dep�h ,� � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if difterent than well location address indicated above /� / <br /> in.f�Ofn `-" t0 + ft. ❑Yes �No ❑Yes ❑ No ❑Unknown <br /> 88t� A8 8� <br /> in.frOm t0 ft. ❑Yes ❑ No ❑Yes ❑No ❑Unknown <br /> in.f�om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � � <br /> Well owner's mailing address if different than property owner's address indicated above Screen from ��� f0-�-.--a.,c-1—ft. Open Hole from SO ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill [�Vo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Y2S ❑ NO Describe <br /> FORMATION <br /> It not known,indicate estimated formation log from nearby well or boring PUMP <br /> t�I�._� r,� '.J TYPe <br /> /�'�� <br /> ❑ 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 ❑ Removed <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> ` J /f r,�/ yy l �1 { 2 � /�9 <br /> Grouling Material ,v�r-t� L.'-�i��,�rom `� to LaL�ft. yards �L.c 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 welt or boring on property? ❑ Yes o 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 is <br /> true to the best of my knowledge. <br /> Don Stodola t�ll Drilling Co., Inc, 27172 <br /> Confractor Busi ss ame License or Registration No. <br /> � :�,'� ��� <br /> or d p e ative Si atur Date <br /> 1Q 1 -_J�,....rl' ../`."a�..,,.�.<JlS�`V-�...... <br /> LOCAL COPY H Z 1 V 1 Z� �� '� <br /> Name of Person Sealing Wel!oi Boring <br />