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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I,,,I�� I�
County Name
WELL AND BORING SEALING RECORD MennlegoNa Unique Well No. �
��� in Minnesota Statutes,Chapter 1031 or W-series No.
(�eave blank ii not known)
Township Name Township No. Range No. Section No. Fraction(sm-►Ig) Date Sealed Date Well or Boring Constructed
Ora�o 117 23 7 4 1��3 �,. � / ..,,�' �
GPS Latitude degrees minutes seconds �
LOCATION: Depih Before Sealing �� ft. Original Depth � ft.
Longitude degrees minutes seconds IFER(S) STATIC WATER LEVEL
Numerical Sheet Address or Fire Number and City of Well or Boring Location �ingle Aquifer ❑Multiaquifer _.
1(VEyL/BORING �Measured ❑Estimated /J '
a!
��+Water Supply Well ❑Monit.Well r
Show exact location of well or boring Skefch map of well or b � "
in section grid with"X" location,showing prope y l ❑Env.Bore Hole ❑Other �/ ft. ,�below ❑above land surface `
�
H lines,roads,and buildin �' CASING TYPE(S)
- - - — -- -- -- — '"t� .
�� [�aSteel ❑Plastic ❑Tile ❑Other s
W -- - - — - -- -- -- E �' WELLHEAD COMPLETION
� � ; � � ,� Outside: ❑Well House Inside: ❑Basement Offset `-
�m'� `� ❑ Pitless AdaptedUnit ❑Well Pit .
-�— -i-- -i-- --�-- � � .,, ,'
A . `� �Well Pit ❑Buried
�im�le� �.�7-��
❑ Buried
PROPJER,�TY OWNER'S NAME/COMPANY NAME CASING(S)
T1117 �.�.t 952-�i72-0246 DiarrrLeete�� � Depth O � Set in oversize hole? Annular space initially grouted?
'
Property owner's mailing address if different than well location address indicated above L
in.from to�ft. ❑Yes [�o ❑Yes ❑ No ❑Unknown
4578 I�enbigh Rd
�' �T �CqC/_ in.from to ft. ❑Yes ❑ No ❑Yes ❑ No ❑Unknown
CI11 J�C)'t
r
in.ffom t0 ft. ❑Yes ❑ No ❑Yes ❑ No ❑ Unknown
WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � r i�
4,` {
Well owner's mailing address if different than property owner's address indicated above Screen from�t0 � t ft. Open Hole from t0 ft. !�
OBSTRUCTIONS
�Rods/Drop Pipe ❑ Check Valve s) ❑ Debris Fill ❑ No Obstruction �
Type of Obstructions(Describe)
--�/i1N/`,� r`"'"��. ¢ c.��-.,� ,
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? S ❑ NO D2SCIibB
FORMATION
If not known,indicate estimated formation log from nearby well or boring PUMP �� �
r'` � TYP
�L / uM�
`' � �'J � -) (�Removed ❑ Not Present ❑Other
(
�
" METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASWGS,OR CASING AND BORE HOLE:
�Vo Annular Space Exists ❑ Annular space grouted with iremie pipe ❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bagt o�f b¢ntonite=50 Ibs.)
Grouting Material /"�1'*� ""���m � to � " ft. yards � ba s
9
from to ft. yards bags
from to ft. yards _ bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused weil or boring on property? ❑ Yes No How many?
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.
Don Stoclola Well Driiling Co. Inc. 27172
Contracto�8 siness Name ' License or Registration No.
�;s- - ,'� :.��_ .:�-.�'�.,� G�/
ut orized R presentative Signature Date
218193 `� k
LOCAL COPY H �� * Y' ~�� ��~���`•~�
Name ol Person Sealing Well or Boring �