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v WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 g fi 3 5 8 COUnty Name WELL AND BORING SEALING RECORD Mnnlesoa�UniqueWellNo. � i� Minnesota Statutes, Chapter 103I or W-series No. (Leave blenk 11 not known) ? Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed ' Occmo li8 Z 3I 5� � � r GPS Latitude degrees minutes seconds Depth Before Sealin g �7� ft. Original Depth ft. F LOCATION: Longitude degrees minutes seconds UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Multiaquifer $0 I�uce Line Ridge� .�r�Q ��Jp� W LL/BORING Measured ❑Estimated Date Measured .�/� nf�� �Water-Supply Well ❑Monit.Well . Show exact location of weil or boring � Sketch map of well or boring �Env.Bore Hole �� in section grid with"X." ^� location,showing property � ❑Other �_� ft. �below ❑above land surface N �\ F lines,roads,and buildings. CASING TYPE(S) �C ''� --'---'-- -'`----'-- , Steel ❑Plastic ❑Tle ❑Other___ � --�--' "'�--' "-`-''--`" `�� WELLHEAD COMPLETION W � � � , E � C � __�___ __;___�_____r__ T � i Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset . 'h Miie . �Pitless Adapter/Unit ❑Buried ❑Well Pit L� ❑Buried --- -- � '�, ,. ❑Well Pit S .� ❑Other �-1 Mile—�� v�r✓ ❑Other ' PROPERTY�O/yV NER'S♦NAMEr�/C�.O..MPANY NAME CASING(S) 13/ le iiil�t Diam e�� • Depth//�� Set in over ize hole? Annular space initially grouted? Property owners mailing address if different than well location address indicated above �in.from � to /'��C7 ft. ❑Yes �o ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE i / � Well owner's mailing address it diflereni than property owner's address indicated above SCreen from��t0 `��ft. Open Hole from to ft. � OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ��Debris J 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 from nearby well or boring. r "� � � Iq TyPe �� " U❑Removed �Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Ezists ❑Annular Space Grouted with Tremie Pipe ❑Casing Pertoration/Removal in.from to ft. [�Perforated ❑Removed in.from_ to ft. ❑Perforated U Removed Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite-50 Ibs.) Grouting Materia�/v�/'�� C...L��/ from� ro�,R. yards �t bags � trom [o fl. yards bags trom to R. 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,Chapter 4725.The information contained in this report is true to the best of my knowledge. Dos Stodols We21 I}ciI#.�g Cc>i. It�. 169I • —.__—_ _ — -- -- Licensee Business Name License or Registration No. i ./'' � `' � ��.:.� ��.� - ! / rtif Re esentative Sign�t�ti - Certified Rep.No. Date LOCAL COPY H �`+�^�( /}+(� �"'�t-'.��ti \../''--��w �.p.�s r� 2�o,J�J�4./ Name ol Person Sealing Well oi Boring , HE-01434-12 IC#140-0423 �` siosa A .. .. . . . . .:. . . . . .