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WELL OR F�ORWG LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I ` WELL AND BORING SEALING RECORD Menn'esoNa Unique Well No. � �� ' County Name r � ` Minnesota Statutes,Cha ter 1031 or W-series No. P (Leavo blank il no[known) �` Township Na e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed '' '' '' 22 5�(' O(o /'}/� , GPS Latitude degrees minutes seconds Depth Before Sealing �`-�'�u ft. Original Depth_ ft. LOCATION: Longitude degrees minutes seconds AQ IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and Ciry of Well or Boring Location �ingle Aquifer ��]Multiaquifer �/ �.,,c. �Q WELUBORING Yy Measured �Estimated Date Measured�l/�_. /�� � ��Water-Supply Well ❑Monit.Well Show exact location of well or boring S h map of well boring :—�Env.Bore Hole Other ft. �y{below above land surface in section grid wiih"X" �o ' erty ❑ � A� C� N ` in� oads,and buil ingsj CASINGTVPE(S) 'S �1 --'--—'--- I I ;. ; ; ; ; � `�y3 eel ❑Plashc ❑Tde ❑Other ---`— '. St :. ` --'-----�--- ---�-- ---'-- � WELLHEAD COMPLETION � W : ; : ; ET __ _ � Outside: �_I Well House i.�At Grade Inside: ❑Basement Offset ; � ; : '{�Mile itless A p rNnd �_�Buried ❑Well Pit , , , � �P� da te � „ . --.--- --r-- --�- - � l , : ' ' ' ' []Well Pit ❑Buried S �—i Miie—� �� [�Other ❑Other P�PERTYO�fWNE-'SdQME/GpMPANXNADAF.� �T^ CASWG(S) 1�1��1oyt SSU11 i�u�.. G" Diam ef� � Depth � Set in oversize hole? Annular space initially grouted? Property owner's maiiing address if different than well location address indicated above �_in,from D to/�� ft. �]Yes �No ❑Yes [�No ❑Unknown 7�►(37 W8qZaC8 $1VL1 St !J[)LLl$ �lir�� I�i+ffi5426 in.from to ft. �]Yes [�No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � /� ��/� 1 Well owner's mailing address if diflerent ihan property owrer's address indicated above Screen(rom �v� to�J(�!_ft. Open Hole ffom to ft. OBSTRUCTIONS ❑Rods/Drop Pipe [�Check Valve(s) ❑Debris �,_�Fill �No Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log trom nearby well or boring. tf� �.�CV TYPe '� ❑Removed I�Not Present ❑Other r� METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from ro_.__.___._ft. ❑Perforated ❑Removed in.from to .___ft. ❑Perforated ❑Removed Type of Perforator_ [l Other _ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) ' + � Grouting Materia �A' V—�� from �� yards bags � � to R_---- from to ft. 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? ❑Yes �No How many?_ LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapfer 4725.The information contained in this report is true to the best of my knowledge. ' Don Stodola Well Dcillin� Co., Inc. I691 Contracfor Business Name License or Registration No. ; //. �� c� i ie e resentative Signature Certilied Rep.No. Date LOCALCOPY H �``' �-Y��— ��y`�-�Y� 2 5 4 9 6 2 Name of Person Sealing Well or Boring � HE-01434-09 IC#140-0423 � s/asa