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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring /� <br /> W@LL OR BORING LOCATION Sealing No. H `7 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave sunk if not known) <br /> Township Name Township No. I Range No.Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed <br /> Ornnn 117 23 07 1 AJ JW/. 31400 Q <br /> f <br /> GPS Latitude degrees minutes seconds Depth Before Sealing ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds AQ <br /> U ER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location gle Aquifer ❑Multiaquifer ,�/ <br /> 8�fA �a 11.. q'j WE BORING L�Ipeasured E]Estimated Date Measured <br /> 20 fbc" Shore DL Orow 55%4 ter-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 v� ft. Xelow ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> .4� Steel ❑Plastic ❑Tile ❑Other <br /> --'------L -- WELLHEAD COMPLETION <br /> W E �\ <br /> TOutside: Well House ElAt Grade Inside: [ asement Offset <br /> 'h MilePitless Adapter/Unit E)Buried El well Pit <br /> , s , <br /> ❑Well Pit ❑Buried <br /> 1 Mile ❑Other ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> vavoDismay, t Depth(j/�/.��( Set in oversize hole? Annular space initially grouted? <br /> Property owner's maili address if different than well location address indicated above � in.from 4 to q— ft. ❑Yes >(NNo ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 2 of 2 in.from to ft. ❑Yes <br /> ❑No E]Yes ❑No L]Unknown <br /> WELL OWNER'S NAMEICOMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above Screen from---0$04!+ <br /> rom+ to---! � ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> [ {ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) -LyAlo . -Z <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FORMATION FROM TO Obstructions removed? (es E]No Describe <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> Iftift © s Type <br /> ❑Removed ^ot Present ❑Other _ <br /> METHOD USED 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 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material tV164 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 Xo 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 /> Don Stodola Well frilling Cos. Inc. 16% <br /> Licensee Busine a e License or Registration No. <br /> 9-S-M <br /> e epresentative Sig ure Certified Rep.No. Date <br /> H 274376 'lu Anton"Lw•::CL COPY Name of Person Sealing Well or Boring <br /> HE-01434-11 ICk 140-0423 2/08R <br />