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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H ��4 3 2 7 County Name WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. Minnesota Statutes, Chapter 1031 or W-series No. (Leave blenk�it no�knownJ Township N e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed / / t 5�[ / GPS Latitude_. degrees minutes seconds Depth Before Sealing �� ft. Original Depth ft. LOCATION: Longitude degrees minutes � seconds �FER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City oi Well or Boring Location Single Aquifer ❑Multiaquifer �n /��1 �+ h W WBORING Measured �_]Estimated Date Measurec�,�/`'�� Ul�� � a7 V � Water-Supply Well ❑Monit.Well / Show exact location of well or boring Sketch map of well or oring in section grid with"X° location,showing pro rty ❑Env.Bore Hole ❑Other 1� fL �elow ❑above land surface N lines,ro�s,�d build gs. CASING TYPE(S) - -- ------ ----- �- � Steel ��Plastic [�Tile �_]Other ,� WELLHEAD COMPLETION �„ ; : ET . ' � � : Outside: ��Well House ❑At Grade Inside: ]Basement Offset � ��. ------ --------F-- --:-- s �;:� �;. , , , , Miie �Pitless Adapter/Unit � uried ell Pit �{ '� ❑ -1 g W " --;-----�-----�----�-- I ❑ uned B ' ' S ' L , � ❑Well Pit � �� Other ; �nn�ie� ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Dia t�r� �,`� Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above ��n.from � to_! � ft ❑Yes �No ❑Yes ❑No ❑Unknown �� "�t in.from to ft. ❑Yes [_j No . ❑Yes ❑No ❑Unknown asyzata, �3 5539i 1 of 2 a�E�:Geor e Stic�aAey in.from to ft. ❑Yes ❑No ❑Yes ❑No ; .i Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � � Well owner's mailing address if diHerent than properry owner's atldress indicated above Screen from_�� to ��✓ ft. Open Hole ffom to ___ft. OBSTRUCTIONS �Rods/Drop Pipe [.'.Check Valve(s) ❑Debris ❑Fill ❑No Obstruction Type of Obstructions(Describe}..1/'v'Nt� l .�/�f ¢ �f.��f� GEOLOGICAL MATERIAL COLOR HARDNESS Oa FROM TO Obstructions removed7 [�es ❑No Describe ' FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. /� . Type ��)/`.� �!1/71� r N 1�Removed ❑Not Present [�Other METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: [�lo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe U Casing Perforation/Removal in.from _to__ fl. ❑Perforated ❑Removed in.from to ft. �]Perforated �,�]Removed Type of Perforator ;J Other r a GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �q� -�- /_ I / � Grouting Materia�'��L/""�"'�-j/ from Q to �v�ft. yards� bags � from to ft. yards bags __ _ from to R. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on properry? ❑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. � Dan Stodola Wtll Drillfng Co,, Inc. 1692 Licensee Business Name License or Registration No. � ��- � � � r e �epresentative Signa e Certified Rep.No. Date �c�� ;o=•r H 264327 �� -�� Name ol Person Sealing Well or Bor � HE-01434-10 IC#140-0423 . � 5/o7a � -._.. ....... . _ . . _.. ..... .. .... . :.... .....,....... ._:....:._..._......,._.. ....�.__ a _......... _.-�.a_...:._......_.__�.-�_ .�.__........:....__._.._. . .. .�,... .__.,.. ..._......,�........._.:....._..�,._....._:_ ..,..