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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 0")/{ <br /> Seal <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnleso aoUnique Well No. JJ `t <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hmrwpin (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed <br /> Or 117 23 0-1 NO',W ZZ- <br /> GPS Latitude degrees minutes_ seconds Depth Before Sealing ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds <br /> IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> 8�}(� 1L�s. raw �j'�( W L/BORING Measured ❑Estimated Date Measured S 1�mG /-'►' <br /> 2 lw th �m fts 5I_! ' Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other J ft. )pelow ❑above land surface <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> c <br /> Steel ❑Plastic ❑Tile ❑Other <br /> '-''-'" j <br /> WELLHEAD COMPLETION <br /> w Y�� <br /> Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> '"itless Adapter/Unit ❑Buried ❑Well Pit <br /> --r---- <br /> ❑Buried <br /> 3 ❑Well Pit <br /> ❑Other <br /> 1 Mile F-1 Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Raverts Diam> f r Depth t Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above 6.e f ❑ ❑ ❑ ❑Unknown <br /> in.from �` to �✓ ft. Yes No Yes No <br /> in.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 r If <br /> Well owner's mailing address if different than property owners address indicated above Screen from to-- 7—ft. Open Hole from to ft. <br /> OBSTRUCTIONS ,�/ <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill I/ c Obstruction <br /> Type of Obstructions(Describe) r <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? L]Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If nol known,indicate estimated formation log from nearby well or boring. <br /> Type <br /> ❑Removed lot Present ❑Other <br /> W0ODUSED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 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 Ibs.,one bag of beptonite=50 Ibs.) <br /> Grouting Material V,�4 6-zl�?,:5"Trdtn 10--'777—If 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 Mo 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 /> Dan Stodola Well Dri111ng Co,. Inc. 16% <br /> Licensee Business Name License or Registration No. <br /> d<9 <br /> CiWifieR6#resenffive Signature' C"""ertified Rep.No. Date <br /> LOCAL COPY H <br /> 270242 <br /> Name of Person Sealing Well or Boring <br /> HE-01434-10 IC#140-0423 5/07R <br />