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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 'I "r%0 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minn'eso a°Unique Well No. - <br /> Minnesota Statutes,Chapter 1031 or W s erieskNo. <br /> %[1LiC� <br /> Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed - <br /> o P 4 <br /> GPS Latitude degrees minutes___ seconds Depth Before Sealing /f,tel ft. Original Depth ft. <br /> LOCATION: Longitude degrees__ minutes seconds <br /> AIwIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ogle Aquifer ❑Multiaquifer [ r <br /> teeasured ❑Estimated Date MeasuredWE ORING <br /> 80 Mirth S Dr. ftow 55 " - r-Supply <br /> Well ❑Monit.Well � <br /> Show exact location of well or boring Sketch ma well or boring El above land surface <br /> in section grid with"X." location, owin erty ❑Env.Bore Hole ❑Other ft. elow <br /> N lines,roads,and build s. CASING TYPE(S) <br /> --i----`-- <br /> XSteel ❑Plastic ❑Tile ❑Other _ <br /> --'--'-' ---- -' -' WELLHEAD COMPLETION <br /> , T <br /> W EI <br /> Outside: E]Well House Grade Inside: ❑Basement Offset <br /> Mile IteesslAdapter/Unit ❑Buried ❑well Pit <br /> ❑P' <br /> T <br /> ❑Well Pit ❑Buried <br /> S E]Other <br /> / <br /> �1 Mile y f , ^ ❑Other <br /> PROPERTY OWNER'S NYAME/COMPANNAME{Lj„�, CASING(S) <br /> Diameter* 01 Depth ' Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing addres if different than well location address indicated above <br /> in.from to ft. ❑Yeslo ❑Yes ❑No ❑Unknown <br /> n.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE It <br /> Well owner's mailing address if different than property owner's address indicated above Screen from // to l ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> �iods/Drop Pipe ❑Check Valve(s) ❑Debris �[❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)--A? .— �/ CK00-1-A✓�ti_ 9C <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? [A ❑No Describe_ <br /> FORMATION _---_-- -----_ _ —- <br /> If not known,indicate estimated formation log from nearby well or boring. / PUMP _p�,�/ <br /> t /� Type S� �IO t�V m Q <br /> ❑❑Amoved F1 Not Present E]Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> o 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 /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material j0kdtA710 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 AHow many? <br /> LICENSED OR REGISTERED.CONTRACTOR CERTIFICATION <br /> This <br /> ywell <br /> ,foreboring <br /> q(was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> s Rolle, A �M j w dge .... ,+IQ:*• NICs a division of <br /> Don Stodola Well frilling Co., Inc. 1691 <br /> Licensee Business me License or Registration No. <br /> iw <br /> 9�g <br /> Certified epresenfative SignaQpe Certified Rep.No. Date <br /> LOCAL COPY H 274396 <br /> Name of Person Sealing Well or Boring <br /> HE-01434-11 IC#140-0423 2i08R <br />