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we��oR soRiNG�oCarioN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring Cou, Name WELL AND BORING SEALING RECORD Sealing No. H 110 710 Minnesota Unique No. � % _: Minnesota Statutes,Chapter 1031 or W-series No. (Leave blank ii not known) T sh}�'p Name Township No. Range No. Section No. F�tion(Srn.��.) Date Seale Date Well or Boring Constructed �` �`� / � ttf �/'' !� l r 1 ° ��r Numerical Street Address or Fire Number an City of Well or Boring Location . � } �1 / '7 {; 1.��-" Depth Before Sealing ��� ft. Original Depth ft. f / Show exact location of well or boring Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL in section gnd with"X". location, showing property t�gingle Aquifer ❑ Multiaquifer lines,roads,and buildings. N WELUBORING �.Measured ❑ Estimated �Water Supply Well ❑Monit.Well _T_ _T_ __ __ __ __ f•-•. �' ❑ Env.Bore Hole ❑Other •-- � ft. -�below ❑ above land surface � � i � i � � W --r- -�-- --i-- --�-- E CASING TYPE(S) -- -�-- -�-- --i-- � �Steel ❑ Plastic ❑Tile ❑Other '/.mile ---- -�-- --�-- --�-- � CASING Diameter Depth Set in oversize hole? Annualar space initially grouted? S "��J"� C f ��' �t mi�e-�e � in.from � to� ft. ❑Yes ❑ No ❑ Yes ❑ No ❑ Unknown I PROPERTY WNER'S NAME � in.from to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown Properly owneys mailing a�ss i�� i � ��than well location a ress indicated above. in.from to ft. ❑ Yes ❑No ❑Yes ❑ No ❑ Unknown ���; ��/� ��_ _ �,J� �. // „�,.,�.�-L^ SCREEN/OPEN HOLE . �� �l r Screen from T_to��}_ ft. Open Hole from to ft. OBSTRUCTIO WDEBRIS/FILL WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill ❑ No Obstruction Well owner's mailing address if diHerent ihan property owner's address indicated above. Type of Obstruction/Debris/Fill Obstruction/Debris/Fill removed? ❑ Yes ❑ No PUMP TYPe � � GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � RemiQ�ed ❑ Not Present ❑ Other FORMATION If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: ❑ No Annular Space Exits ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other '" GROUTING MATERIAL(S) Grouting Material f:. �' ��� to � : ft. yards bags �. , ,.,L�. t.{., Y� . from to R. yards bags � c from to ft. yards bags from to ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑ Yes Q No LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. .a� �---� - , _, / ` C t�c YBy�ine i�fa" - � �'-`<_ Licens or gi h . . , � f : � , � � i ; . , . J/. , . �.. .�:,' _=�i .�:'r� ., f, . / � th6" _ �gnatu ' bate ♦.,..� . ./ ri ! -,r' f!�'�.�ii g �� � �;' �: �e-'�� . .,or Boang�-�� LOCAL COPY H �_ � � � � O HE-01434-02 10/95R JAN-15-2009 11 : 12 AY9 LEUTHNER WELL INC 952 443 2582 P. v"? ,,;. � NIINNaBGTA DEPARYMENT�r FIlALTN �'N ANO 90RlN/O N�dy����� WEUJBORING�pcArinr� CounlyNeme �i�'�I.L AND BORING RECORD /� 1 �r+�"'""�`r' ���Amp�A M►nn�soa�bruts�,cnapter losr � . 7'�F.I.2 ( 1 �' lawnenip Nam� Tbwnehlp No. Rqnpv No, 8ectlon Na. Fr�otjpn wELU60RIN CPTH(complete0) DATfi WO H MPL T p orano i i� �� ti ��,, ���,,��,,, ��o R. ���6��� �PB LBdCutle__ doB�oeB__ min4t�0�_ ���ay,� DRILLINp METNOO LOCATION: , L CeWe Tbol �,prlvan , f�p�p Longltude_ tlapraa� minutee�, seconde_____ Houne Numbar,SI16'rt N71fitYi Chy,and Zip Code n1 Wall I.00atlan or Flro Numb�l ��A°B�� ��ary, [:]JelleO 1365 S��t pb. �td, Oroao f�Of " � DRILLINO FLUID WELL HVDROFRACTURED9 ['1 Yee �.�� o , 6hcw exaat locanon al welimorihQ In watlon prid wlth"x." tch mep ol w�U Ine�qon, earo�a Qo�x ��1 F�_^ n.T� " �, Showln�propatty Ilnae, U8E :: hH�110 �'7 Monitetln C:I Meetln/Coolln N roedsr,bulldlnpe, 0 9 p 1 ; � rnd dlredbn, lJ Noncommunlry PW6 L.J Envlron.6oro Nol� LJ Induetry/Commerolel ..1•......•-•j--•---• '""" L.-J Corttmunlly PW8 f 1 Irrlgepon �''Remed'ul � L . C�Elevata C.7 DewaierinA L'1 __. _ W"i"'""- --'f��---�� E � � C�gING MATERIAL Drlvr 8hoe7 ''IYea I: o HOLE DIAM. ' U 8teel �„ ..... �,Threeaad f��i Wolded , ...�-- � T��a ��.,uo �, ; --�----- ----=------- 1 �,,s�N� -- � Dl�ln�t�r W�IBht sp�elHo�llon� 8 r' 1 {----t Mlle----{ �In.ta �oOk �,�Ibe,d� a�� ,,, '����t In,ro�o ft. In.tn IL �Ib1;nt•,,,�,.,�� �+in,to�k ' PpOPEpTv 0 NER 8 M ANY N In.� n, ` I�.�,. I,'.'a "',,:!:�h TA�YO AS�aC�1�1d SCREEN OPEN FiOLE ,:��i'';l; . Prapeny owner'e m�lllnp sddrose II dlflerenl Ihen wtll loo�tion addreae Ineleated�bova, Meke � From tt,To ���R �yPa a s Q _— Dlam, � ���.. slotro.u:�,��t-�e� lsnpt��,- SYl bervveen a w V p �nd R. FI7TINGS 'i �'' 97A71C�v�ATBR LEVEL , �o h.��eiow rlAbove land suAece p.�G m���urod 4,,,��6 PUMPINQ LEVEL(below lentl aurl�) �• �: . wEw80RINp OWNER�B Nn►nE�COMPANY NAME � - _n.elter, 1 - - .�.�ro.pumpinp-T--3��--p,p,ln,, LL HEAO GOMPLETION �r=i x �� WeU/oohng owner'e melllnp addreas u tllllehnt ihan property owner'e addrqs Indlcaled utw•d,� �������Adeplar Manuleauror „Model � ��� •,• LJ Ceelnp Prcteo�bn [712 In.abow prade '�AI•pr�de Envlronmeniel W�II�nd Borin ONLV ' Of1�uTINa INFORMATI01� i, � Weu promed7 �YN�_,ND Grout m�4rl�l� N�Neet eeme�l lJ B�ntcnite ['1 Conarete �7 Oth�r,,, From,��_Tb�,R• _��L7 Ydi, ,.(�aPo � . From ,Tv R. (:]Yde. C]Bw� e OEOLOOICAL MATEpIALS COLOA H MA EERIA�F FFOM TO Rrom _1D h, T f]y�, , �_j I�B NEARE OWN BOURCE�F TION �^~ � i�� �� �� ��� ��r ���� ..::� , y�il��r cia�► bro�n •o!ti 31 �e� �re�w� �_ ��': W�II dlolnfeaed upon campl�tlon7 Yee L7 No �i ;: �!�;; � PUMP � bi�� cia rs �ott �3 gf� � ,:,., ,. -�,-�--.� IJ Na�nn�ll�d De �e Inetelletl ,� � I� t;�l �i... . . � � i. Cli�► � ��Qt�l"�� �li]'' SO�ti � �� t�nut�otur�r'e name��0�0�! � ,i �'.���„�I�I'li'�i, ,'�ii':�I Mod�INumber_ MP._._._,,,_Volta,r•r "' � •aAd b=01Ip s0!t 9 1 ZO L�nplh of drop plpe _IG c4�,r �. ''i --,�—�---„—�,}i,�h; rypr�8ubmerelWe CJ�,5.Turbirn �I Recl rocenn L'J J�1 C] ABANDONEO WELLB Doee properry h�w�ny no�In uee end not,reeqd Nwll(e)7 I.1 Yee �IVo VARIANGE Wae e wqo1101 p/�nted Irom Ihe MDF{�01 thl�waN7 L'J Yee ��lo TNN ,�,;� WELL CONTRACTOR CERTIf ICAT10N Thle well wes drIIIW und�r my eupervlelon ena�n wwrdance wltn M���iola piu�w,Ch�pter a785. The Inlormetlon eonuln�d In thle repon le true ro th�bnl oi my knowlaege. uae s aecone aneet,irrr��ovd, L�OtrtlA�t 1��=,� I IIC• ,,' REMARK6,ELEVATIDN,80URCE OF DATA,ete. �LL��� Uceneee Buelnen N�m� Lla.or p,g.No. �J�: i � _ 1':�.'.: dzee Ii�preNntaVw B newre � � � :' ..:��' � � :'jl!I��.:ii;'ii�4i�;�,'; . t�auric� �. L�nthn�s �'�Y���.' '''�� �,�;� �nr.,�� ,�.,-.r�.. I 7 A A rv�� �Neme�nl DrlOar —..,_ ..,.�.._ _��-=-,--r"�'�""':�'�Tfl'� JAN-15-2b69 11 : 1� �ii•1 LEUTHNER W�LL INC 952 443 2582 N. V� �. , .' , • . ' '.' ..li; ��I�',; �LL������� MINNESOTA DEPAFiTMENT OF 11�ALTW ���W����^Q H ��T. o�, rw�.---' WEL� AND BORING SEALINO RECORD �u,,,,�,o�,u�,q�,w.�i No. . n�xu,esor.sdm�n,C�n�prd►�a�J �,,.W„°„��"�,t,�.,g� �Y�p M eMp No. Rrnpr No. 6iollan Ne. Fraadon(�In+la1 Cab�1�0 D�W�II or 9orinp ConWuel�d ;.',j. � � ,�1f . ' .�,. �i � , � M1 �w �•� . 'I: V�1�� d�O��M minut� �antl� f �• I oae D.plh Nfon BaYep n. odp�o.�n rt. � � LAC�TION: ' � Lernpilud� ds�jww� minutN �d� Ap�lI�CNb) �TATIO WA'RR L!V ,; , d 81n a IN► ❑Mu11 uN�l '�..i �i � NumMa�Sfn�W Addrow o�, n um6�r m Iry�W�II or doMp���on � �M�I�M��d a��� ' � ' � �. , ' m�LAC111N0 :i; �' : . • IN�ON BuPD�Y� �MonR Wall i i�� , j!,.� beaUon o�wNl or Oalnp � B ep of wNl of OoN+p In�etlon pdd wRl�'x' haNlnO DroP��1' ❑E�8aie Hoh ❑01hv __�R. 0 b�br 0�Oow(�nd wAao�,� : �,, -A�� , i� i:. aed buUdlnW CASINA TYP�(/) `�' ' N �;,, :I:;. ( 'i� ' ;.. ; •+-• •+• -�-- aw� 0�ienK p 7iw O ouis� `'';, ,�, � ' �, W -fi- •�-- -�-- ..a.. � wa�nu�co�EnoN �� , �•�� o�u��aa� ❑wau Mouu u�aa� �9a.m�a oa.�t 11.I ..�.. .�- .�.. .i-- � � �� ' p,,,�,� O PPo�a Nd�ptMU�t p Nhtl Plt "I ' 1 ` , , ,.. ,., f . • - •�• --i-- d � , , , � P I". ,. �..,.�..,... � : ,.:� � ,..; . , i' . . ::i;t ;lti,� �iJ`i, I i•.!�,.i.j :Ii�f 1.i�' lii�! j;j �,� � p w.0 n ,,...��, :�� ;3�. ;,,..:a,��.�., �: .1'. '�,�' ;'�j�I;k� I�II� ; � �!:, �j,_.._..��—� ' ❑eun.e ''. , �°:,;;i:��i ;,I'; ;;i Pwo�c �►�w�e w► �co P v e crw�Hots► ���:,` ''' �:�� I1i i':�„��; OlamaUr O�pni .,/ 6p In ownl�nor7 AmaJbV�Paoe Inldilt�prouE�d� I P i row N rs�n � � In.Irom� �–�� ❑ri. d No 0 res C�No:;:. p Uniuiown ; � In,trom to, e. p rw Q No ❑ve. ❑No p I�I`� unimown In,lrom w h. p we ❑No ❑v�' ❑No unknown l' � d WELL OWNEi�'9 NAMFJCOMPANY NA6AE dCRiilW?!N F101.� �� '!'��;�� �, I,.,. N1oll oxm�l'o n•,dllrp�dtlnee U tl�larml ihen proDNri owrnr'�addrou Mao��ed.bow 9cre�n 1rom.11�i�to��ft. Op��Flole trom lo�,,_..--N. ' "� ,•,.;,.,,; ��.: �Ie,'i.:� �' , OS6YlIU 1� ,.,..,; �' ' I;I','ll i;'ll'i, i.� � p Rodalorop Plp� C]Cneok VaN�(o) ❑ QaoAa O FIII ❑ No OhstnicHon ;.' : ,.i I�y��{�i..;. i� , i:'i���1 ;��,.�,_ '; ��r��i�'`�<:,��I;I��,;'1l���i�!j� , 7yt;a of Obotri�ione(Daorltief 1:�"� , " �. ��.::.r,���,1;;,'..F,:�.�iir� ��,�;..; , . �I.: OBt31.00i;.A�MATERIAL COLOR H�pQb���� ��Y TO �bsi�uotlone removsd? O Yee ❑No �9ecrlbs F'ORMATIOW , II nol lafawn�Indlow�ellmeled lorm�lun kp Irom rworbY wrll or EoNei PUlAP ' � I: �Yp�_�,.fy�sy�7'�` F3�moved p Not Prsa�nt ❑�►nsr ��' ' Aq�'i'i100 u9�0 TD�lAL AN►�WLAR YPA�!elTW�IN Z CAeIN00,Oq G�WNO AHC s011� 4M� O No AN+ulu Bpta ExIM O ��►�P��0�4�Ih dvmb Dlp� ❑ Cealnp P�Aw��w� � I i,,, : In.lrom to h. ❑ Paitonad� L`] Rsmovst! I� In,froni Oo k. ❑ P�rforated d R�mavotl �� ,i. ,�;:�,. ryprolp��foraror . .. . ,. , , � ��p ,�� ;�-i.:lirF:.a.,:I���r.;1;r...• j li i, . ,;lj�,�;;,�,i;��i►;:,i;i,, ��; ❑ bth�r._., ;�� I�r„I���.� � ,,��- onvur�Na w►teai�ue► �n.ew oe�.m.�,ia,�o�.o.o�e.Mon .�o ia..� � �; � � r��:,��o M.arw � , "� r�om ' �� �o_fL rt. r.rd. ,,,.�.-- buw . i Irom to 1� yard� b:s�� � I. Irom � to 1� y�Yd■ bups'' i; I; 6YFllR WlLLO AND�ORINGa , � I , �; „ . � �� Ni,YARKL,�OU11CG OF DA7A,DIrFlCUL I!91 OCALIN� I I ptnsr un�alod�nn unu�ee well or borin0 on prepeAy4 ❑ ri� No How nuny7 / �1 LtCeN6�D CR RLOIe'TEIIW CONTRAC�Oh C!!1?IPICATION � � , ..�,,(�.,.�.1,)JJ�� r�1,.�`rY�/1.�0'"� TI�I�weu or eod�q wao�al�q u�Qaord.na wlt�Mlee.ee�a Rula�Ch�plu pP6.Tf�Warmalon coM��wd In tloN hpo�t'�O , wa fa Ih�D�N o/my edp�. �"'. � .� � � �! C071hAofbr A�uNwai N�m� � Uco o/1M�phfnNon Nb. , , �� � � �� Gu n O�� , '•�' ' :��" '�; 'li .�y,.__.._..... ,1.��1.�'_ ...,� . ,