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� <br /> WELL OH BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring I ����n a"� � <br /> Counry Name WELL AND BORING SEALING RECORD Sea�ing No. �H O L <br /> Minnesota Unique Well No. � � <br /> Aennspin Minnesota Statutes.Chapter 703/ o�W-series No. <br /> w�c n na w�w�� <br /> Township Name Township No. Range No. Section No. Fracuon(sm.-►Ig.) Date Sealed Date Well or Bonng Consiructed <br /> 4rona 117 23 8 . ,. Zt � � C� <br /> Numencal Street Address or Fire Number and Ciry of Well or Bonng Location � t <br /> 353.0 At Sho�e Br, flrono 553�l1 � — <br /> Depth Betore Sealmg �� � R Onginal Depth �� n� <br /> Show exact locatwn of N�ell or bonng ��Sketch map ot well or bo�ng AO IFER(S) STATIC WATER LEVEL <br /> in section grid wdh"X'. 1�'�"�ylocahon, showing prop y Single Aywter � MWhaquifer <br /> '-Y lines,roads,and building . � <br /> N - WELUBORING Measured ❑ Estimated <br /> � �1Nater Supply Well ❑Monit.Well — — � <br /> .�'� <br /> ❑ Em.Bore Hole ❑Other , � R �j below ❑ above land surface <br /> W -- - - '- - -- -- -- E � CASING 7YPE(S) <br /> I I <br /> � � � � <br /> -�-- -;-- -;-- --i-- �Steel ❑ Plastic �Tile � Other <br /> yimile <br /> > -�-- -i-- -i-- --�— � CASING(S) <br /> S ' Diamete%' Depth � / Set in oversize hole7 Annular space initially grouted7 <br /> �1�—t mae� -�' � in.from C.-/ to /��-� ft. ❑ Ves �No ❑ Yes ❑No ❑ Unknown <br /> � -y�-,. .� � g_ ��,__,,. . <br /> PROPERTV OWNER'S NAME m.trom to fl. ❑ Yes ❑No ❑ �es ❑ No ❑ Unknown <br />�,,,. i i Ine n tio ss indicated above. in.from to tt. ❑ Yes ❑No ❑ Yes ❑No ❑Unknown <br /> 2689� Rlob2e Rd SCREEWOPEN HOLE <br /> r �f�` i <br /> Shore�►ood� MN 5 5331 Screen from �d� ro� R Open Hole from to tt. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �Rods/Dro Pi ( ) ❑Debris ❑ Fill ❑No Obstruction <br /> p pe ❑Check Valve s <br /> ..-- <br /> �- /� / �'^ <br /> Well owners mailing address it diflerent Man property ownars address mdicated above. Type ot Obslructions(Describe) �/uN��� r/� �"- �/ � � <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP <br /> Type <br /> (iEOLO(31CAL MATERIAL COLOR HARDNESS OF FROM TO � Removed [�C Not Present ❑ Other <br /> FORMATION <br /> It not krawn,indicete eatimated fortnatbn log from nearby well or bonng. �METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> r ,LS.No Annular Space Exists <br /> v Q ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to R. ❑ PeAoreted ❑ Rertroved <br /> in.fiom �p ry, ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> �^' / <br /> Grouting Material ���� ���F'�Kom � to� ft. yards � bags <br /> from to R. yards bags <br /> from to ft. yards bags <br /> from to__ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICUlT1ES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation confained in Mis report is <br /> true to the best of my knowledge. <br /> Don Stodola ide21 Drilling Co., Inc. 27272 <br /> Contractor Business N e - � f License o�Regishafion/io. <br /> `� �'� r � ,�� :�� <br /> mo •nr , srgnerure Dere <br /> _ .----� -....�. <br /> �`:, J ;� � <br /> . . �}Y��,Q�S Y � <br /> l.�DCAL CO�PY H ����p� Neme o/Person Sealing Al/or Bonng <br /> V `J <br />