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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring t„� ^� {� WELL AND BORING SEALING RECORD MennlesoNa Unique Well No. �" ��`� "�� CpE�nty Name' - - Minnesota Statutes,Chapter f031 or W-series No. � ��;;/,;j Ner�ne ia «aa�a e�a�k,,�o��,ow�, Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed � f?cono 117 23 09 S� NW SW 5'€ p % - ! 'i � � GPS Latitude degrees minutes seconds Depth Before Sealing �� ft. Original Depth '1� ft. LOCATION: Longitude degrees minutes seconds A UIFER(S) STATIC WATER LEVEL �r Numerical Street Address or Fire Number and Ciry of Well or Boring Location ��Single Aquifer ',]Multiaquifer t�,n WELL/BORING y�Measured ❑Estimated Date Measured.'"`�#,/n� l Yt� Water-Supply Well [�Monit.Well � Show exact location of well or boring Sketch map of well or boring i Env.Bore Hole ❑Other � � [�above land surface in section grid with"X." / location,,showing pr erty G �ft. beiow N /� � �nes,road�,a;d bwldi s. , CASING TYPE(S) 1�/ 4.fi��(.•_ ��,� F. ,: --'--- --'-- --`----'- ' I�Steel I�Plastic �Tile ❑Other ' --'--- --�--- ---`-- '--`-- �� WELLHEAD COMPLETION = W ; : ; ; ET �� i _ :�� Outside: �]Well House �At Grade Inside: ❑Basement Offset � 'h M'ie �Pitless Adapter/Unit ❑Buried �]Well Pit --.-- --;-- ---------=-- 1 ❑Buried ' S ' - [_]Well Pit ❑Other �1 Mile� ❑Other PRbO�PERTY OW�1NER'S NAME/COMPANY NAME CASING(S) DCt t YD' t Diameter � Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diNerent than well location add�ess indicated above �� -, �in.from� to��ft. �Yes �No ❑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 f � Well owner's mailing address if different than propeRy owner's address indicated above Scfeen from��to��,__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 pROM TO Obstructions removed? ❑Yes ❑No Describe FOHMATION PUMP If not known,indicate estimated formation log from nearby well or boring. Type_ �""� J � � ❑Removed �ot Present ❑Other / s METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists �]Annular Space Grouted with Tremie Pipe I.�Casing Perforation/Removal in.from to ft ❑Perforated ❑Removed in.from to R [j Perforated ❑Removed Type of Perforator r- ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite-50 Ibs.) r Grouting Material/�/.�% ('��,�JT from U to� ft. yards�� bags �rom to R. yards bags _.__ from 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 ta the best of my knowledge. Dc� Stodola W�12 Drfllin� Co., Inc. 1b91 ` Licensee Business Name License or Registration No. - - y� � � �J e ed epresentative Signature Certified Rep.No. Date LOCAC.c:OPY � ��0�� i�� J�c7�.�J Name ol Person Sealing Well or Boring HE-01434-12 IC#140-0423 J siosR