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V�ELL OR BORING LOCATION ' MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 'H ��C��Q County Name WELL AND BORING SEALING RECORD Minn�esoNa Unique Well No. �' �� ?��_—q�p�� ^ Minnesota Statutes,Chapter 103/ or W-series No. +�..i�1lA irii (Leave blank il not known) Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed Oto� 1$ 23 't►1E ''�1'' 1 _C 4 +� , �� GPS Latitude _ degrees__ minutes ____ seconds Depth Before Sealing /U ft. Original Depih_ ft. LOCATION: Longitude ____ degrees_ minutes seconds -- ---�-�— Q IFER(S) STATIC WATER LEVEL � � Nu��ric�al Street. Address orT F�NumDber and;ityo Wel��l or�Borin�535� ingle Aquifer ❑Multiaquifer ,[5 /�y�,� i�no Measured � Estimated Date Measured 1�'� !/"'� ��5 aw�►ab LI�Rt Dl� �W(E�''.U' BORING � � � L�7wvater-Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or boring �p I in section grid with"X." location,showing property ❑Env.Bore Hole ❑Other h. �below ❑above land surface lines,roads,and buildings. N CASING TYPE(S) � --'-----'--- ---`-----'-- � �Steel ❑Plastic [�Tile �]Other "'"' "�'-' '-'`" "''- WELLHEAD COMPLETION �� W ; ; ; : T � __�__ _;__ __�__ __�__ Outside: ❑Well House I�'��At Grade Inside: ❑Basement Offset '�� Pitless Adapter/Unit ❑Buried ❑Well Pit , ; � / _ ❑Buried L �(/ ❑Well Pit S "tNG 1 e i 1 Mile—� � v.�Q.�r ❑Other ❑Other PROPERTY OWtN7ER'S NAME/COMPANY NAME CASING(S) � r Dia�me/yerJ/ � Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diflerent than well location address indicated above '7 In.ffom Q to �/ ft. ❑Yes [�o ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to n. [)Yes ❑No []Yes [j No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � i �/7(� Well owner's mailing address if diRerent than property owner's address indicated above SCfeen ffom �� to ` �'" ft. Open Hole ffom to _ ft. OBSTRUCTIONS �Rods/Drop Pipe (�Check Valve(s) ❑Debris ❑Fill L]No Obstruction � Type of Obstructions(Describe)��/�/�� / _�F��_.__4"_ �U�� _ , — GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? I�es PORMATION ❑No Describe If not k wn,indicate estimated formation log from nearby well or boring. PUMP n 0 I TYPe �V� '"` C1�A �emoved _Not Present `J Other METHOD USED TO 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 to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed � ti Type of Perfora[or - ❑Other ___ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) � /�/ r � , Grouting Material�� C..'Cl/�/v om � to �� ft.______ yards � bags 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 ,�o How many? �k LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules.Chapter 4725.The information contained in this report �S�rU�:�:S�:�`�e��1e�rilling Co,. Inc. a divi�#ion of don Stodola �Tell Dri2lingCo., Ir�. 1691 .. - --- - ----- -__ ___ __ Licensee Business Name L�cense or Regrstration No. � /�,� /�,2 U� C es ta�ve Signatur � Certilied Rep.No. Date H 275489 �� ' ; LOCAL COPY � Name of Person Sealing Well or Boring - � ----- -- ___ .___i__ , HE-01434-11 IC#140-0423 ' 2/oaR a