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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �{,� /� �� ? WELL OR BORING LOCATION Sealing No. H L)'�t '" � County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. ' Minnesota Statutes,Cha ter 1031 or W-series No. +�� P Leave blank�ii no�known) 1 Township Name Township No. Range No. Section No. Fraction(sm.-•Ig.) Date Sealed Date Well or Boring Constructed , OCOII� I17 � U7 � "I�U9� � �Y � C�rI ; . GPS Latitude degrees minutes__ seconds Depih Before Sealing_�ft. Original Depth ft. �OCATION: Longitude degrees minutes__._ seconds IFER(S) STATIC WATER LEVEL ¢ Numerical Street Address or Fire Number and City of Well or Boring Location � ingle Aquifer ❑Multiaquifer �n�` A�� easured i,- i Estimated Date Measured �7��T' �Y`T s I377 North Arm �, Ocorb 55364 �,"B�R�"G � —_ ater-Supply Well ❑Monit.Well l' Show exact location of well or boring Sketch map of well or r g� , �LJ � in section grid with"X° location,showing prop ty �� _,Env.Bore Hole []Other �ft. ' `pelow !]above land surface N lines,roads,and. s. � CASINGTYPE(S) --'-- --'--- --`----`-- � �Steel [1 Ptastic �J Tile ❑Other ��- � --'-----'--- ---`-- ---`-- ELLHEAD COMPLETION W � � , � E — W . __�_____;.__ __�__ .__�__ T �!y Outside: I�_1 Well House �,r]At Grade Inside: �_!Basement Offset � '/M;ip r ,Well Pit I I I I � „ �� -� � � � � � a k ess AdaptedUnd �. Buried �_ , , , , 1 �P�� ------ ------ --.-----:- ; ; ; ; o � � ,_ ❑Buried �Well Pit S � 'Other �t Mile—� �]Other y P P WNER'S1N�A�MEt/CtOs P NY NAME CASING(S) ��il� r�l�� Diam�►ey� � Depth f Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above �J / in.from D to �� ft. ❑Yes ;�o �Yes ❑No �]Unknown in.from to ft. I]Yes ��,No [l Yes ❑No rJ Unknown in.from to ft. ❑Yes ❑No [�Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE� , Well owner's mailing address if different than property owner's address indica�ed above Screen from_�O to + �ft. Open Hole from to fl. OBSTRUCTIONS [�Rods/Drop Pipe ❑Check Valve(s) J Debris [�Fill ��o Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes �.J No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. !,�^�►� '7(/ Type V �'`j' 'J ! 7 ��Removed Not Present ❑Other .__ � i METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: I�Jo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe [i Casing Perforation/Removal S� in.from to __ft. ;J Perforated , i J Removed i - in.from to ft. ❑Perforated [;Removed Type ot Perforator . x j_j Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) i' n /�/ � � Grouting MateriaJ/��/+�� CJ�.' ��rom�� to� ft, yards_� bags 7 ' � _ from to ft. yards bags from to _ tt. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes I o 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. Don Stadt�la �lI Driilf.ng Co., Inc. i692 Licensee Business Name ' � e/"S License or Registration No. , -�`'� ��_ f� �,Z. �? � � d epiesentative Signature Certilied Rep.No. Date � : 't r.-_ , LGCAL.�GPti' H i��Z� 1 `'�"Y-y.,.. �_.�., ,,��;y�,C.fy � Name ol Person Sealing Well or Boring . HE-01434-10 IC#140-0423 ' . S�p�R