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�/VELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I �}�C/9 � <br /> County Name <br /> WELL AND BORING SEALING RECORD Minneso a�Unique Well No. �, g'•�r <br /> �p�� Minnesota Statutes, Chapter 103I or W-series No. <br /> (Leeve�lenk it not knownf <br /> - Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> t}rc�o I17 2 U8 34-Q�U19 // ,��. <br /> �j i <br /> GPS Latitude degrees_._ minutes seconds Depth Before Sealing I � ft. Original Depth ft. <br /> LOCATION: Longitude _ degrees minutes seconds <br /> A�UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer � � _ <br /> 3570 North Shore Dr ��� 55391 WE UBORING �Measured [)Estimated Date Measured��� - � <br /> � �Water-Supply Well ❑Monit Well �f�' " <br /> Show exact location of well or boring ap of well or boring � Env.Bore Hole <br /> in section grid with"X:' location showing property �-� ❑Other ,,,� ft. �below ❑above land surface <br /> N lines,r ds,and buildings. CASINGTYPE(S) . <br /> 1 ; I � � `, <br /> �, Steel ��Plastic ❑Tile ❑Other <br /> --'-----�--- ---�-- ---`-- � WELLHEAD COMPLETION , <br /> W ; ; : ; ET "�,��� <br /> ��. __;___ __�___ __�_____r_ Outside: ❑Well House ❑At Grade Inside: y��,/Basement Offset <br /> 'h Mile ❑Pitless Adapter/Unit ❑Buried _I well Pit <br /> --;--- --.--- ------------ 1 <br /> ❑Buried <br /> ' ' S ' ' ��f Well Pit <br /> �-1 Mile� � �_,, � �,� []Other ��Other <br /> /�I`�-,�r.l�__ _ <br /> P OPERTTy�O�WNER'S NAME/COMPANY NAME CASING(S) <br /> �� ++�+=Z Di�eter ` Depth _ � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above �� <br /> •...• in.from� to��ft. ❑Yes �No ❑Yes ❑No ❑Unknawn <br /> 258 Cyr�et Ple�ce <br /> 0�� � 5535b in.from to ft. ❑Yes [;No ❑Yes ❑No ❑Unknown <br /> f <br /> in.from to _ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> � <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � <br /> / t <br /> Well owner's mailing address if different than property owner's address indicated above SCreen from f.:.-`� to �� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> [,l Rods/Drop Pipe �]Check Valve(s) j�Debris ��Fill �o Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �]Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> r�� Type <br /> P--' %`� <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 [J Casing Perforation/Removal <br /> in.from to ft. i�Perforated I�Removed <br /> in.from to ft. ❑Perforated �i Removed � <br /> f <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> _ � <br /> A ' ..� .� <br /> GroutingMaterialiVf/—J/ �/�'<<l��from� to �� ft. _ yards J bags <br /> from to ft. yards bags <br /> from ro 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 o 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 �+ <br /> is true to the best of my knowledge. <br /> Doa Stodola Well Dril2ing Co., Inc. I691 <br /> Licensee Business N e ., License or Registration No. <br /> �� !'��� I�J � i..' <br /> �lI i" <br /> t Representative Signature Certilied Rep.No. Date <br /> {'�� ; <br /> 664 55 �.'�-� ,�.,� � z <br /> LOCAL COPY H � �L� <br /> Name of Person Sealing Wel/or Boring <br /> HE-01434-10 IC#140-0423 5/07R . <br /> i <br />