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,.-R� �. . �.�.; __ _ _._.: , _ _ . __ _ <br /> wELL OR BORING�oCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' � <br /> Sealing No. <br /> CountyName WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> ��i� Minnesota Statutes,Chapter f031 or W-series No. <br /> (Leave blank�I not known� <br /> Township Name Township No. Range No. Section No. Fraction(sm-i Ig) Date Sealed Date Well or Boring Constructed <br /> 4rono I l l 23 6 41-0086 � �F L a <br /> GPS Latitude degrees minutes seconds � � <br /> LOCATION: Depth Before Sealing �� ft. Original Depth �� ft. <br /> Longitude degrees minutes seconds IFER(S) STATIC WATER LEVEL <br /> Numerical SVeet Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> 1345 I� Ar� D�c �L'Qj�Q ��7� UBORING ,�leasured ❑Estimated <br /> �VJater Supply Well ❑MoniL Well t <br /> Show exact location of well or boring SkeYch map of well or oring <br /> in section grid with"X" location,showing pro rty ❑ Env.Bore Hole ❑Other �ft. �elow ❑above land surface <br /> N line�,and buii ngs� CASING TYPE(S) <br /> � Steel ❑Plastic ❑Tile ❑Other <br /> W -- - - - - -- --;- E � WELLHEAD COMPLETION d <br /> � � <br /> r , � � �_^—� Outside: ❑Well House Inside: ❑Basement Oftset '� <br /> --- -�-- -;-- -�-- �, <br /> � y�mi�e i� � Pitless AdaptedUnit ❑Well Pit � <br /> -�-- -i-- -i-- --�- � . �� '� � <br /> •f.i� \ ❑Well Pit �Buried <br /> s 'r � <br /> �—""'b—--� � ❑Buried <br /> P PERTY O ER' NF�AE/COMPANY NAME CASING(S) <br /> �Cat C �ze�Cet.� Diam ter�� Depth,r��ry t Set in oversize hole? Annular space initially grouted? <br /> Property owner's malling address if diflerent ihan well location address indicated above }��y+( <br /> in.from� t0�L ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.fforrl 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�t0 �� ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) —�/tf/�`� /---�'� �" • U�� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Y2S ❑ NO DeSC�ib2 <br /> FORMATION <br /> If not known,indicate estimated forma�ion log from nearby well or boring PUMP <br /> Type �C�, pV�� <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. ❑ Perforated ❑ Removed <br /> r <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> I, /j��/� /'� t <br /> Grouting Material,N����-/���•'�-'�from�S.L to��ft. yards � 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 well or boring on property? ❑ Yes �Jo 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�ell Drillin�, Co., Ir�. 27172 <br />� � Contractor Business Name License or Registra�ion No. <br /> __ /�% �� �:.� <br /> A ori presentative Signatur�__ Date <br /> ' C`�y l- -- <br /> LOCAL COPY H ���O V V r � ��"�..�'Y~� <br /> :-V.,. �. <br /> Name of Person Sealing Well or Boring , <br />