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_L OH BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' ��O�'1 Q� <br /> uunry Name <br /> WELL AND BORING SEALING RECORD MennlesoNa Unique Well No. `J V <br /> Henciepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (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 /> Octimo 117 23 7 4 1,25 ;, , _ <br /> c <br /> GPS Latitude degrees minutes seconds � Q � <br /> LOCATION: Depth Before Sealing 4� ft. Original Depth !� ft. <br /> Longitude degrees minutes seconds qpU1FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> 2256 Shadywood Rd, �rano 55391 WELL/BORING �ileasured ❑Estimated <br /> �Water Supply Well ❑Monit.Well � <br /> Show exact location of well or boring Sketch map of well c� g �( /� <br /> in section grid with"X" � location,s �' ❑Env.Bore Hole ❑Other v ft. �elow ❑above land surface <br /> N � lines,roa ,and buildin s. CASING TYPE(S) <br /> r � izSteel ❑Plastic ❑Tile ❑Other <br /> T� <br /> W --�- - -- - -- -- — E � WELL.HEAD COMPLETION <br /> � , � , � Outside: ❑Well House Inside: ❑Basement Offset <br /> -,-- ;-- ' i-- � � <br /> , �m��� ❑ Pitess AdaptedUnit �Nell Pit <br /> � � � � � <br /> -i-- -i-- -i-- --�-- 'tj �� �. <br /> \. ❑Well Pit ❑Buried <br /> S / r <br /> �i mde—� t.. <br /> ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> � Diameter Depth ! Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address it different than well bcation address indicated above �� �j�f <br /> � in.ffom � to�ft. ❑Yes [�lo ❑Yes ❑No ❑Unknown <br /> In.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> l � <br /> Well owner's mailing address if different than property owner's address indicated above Screen from�t0��ft. Open Hole from t0 Tt. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) .��/n 1/� /"��!-^_ ¢ ,f� � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ES ❑ NO D@SC�ib2 ' <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP -�^ ,/� <br /> � Type U f T ( U M n <br /> �' � � �llRemoved ❑ Not Present ❑ Other <br /> 7�. <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 Ibs.,one bag of bentonite=50 Ibs.) <br /> A fa�f17`�c^L�?'I/.f�t�'T Q� r <br /> Grouting Malerizl /� �to_�tf2 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 No How many? - <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapier 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Don Stodola Well Drilling Co,, Inc. 27172 <br /> Contractor Business lame --- License or Registration No. <br /> � �( G..� <br /> A ri e resentative-Signature Date <br /> ���:. , ���.��,Q,�tY�� <br /> LOCAL COPY H 210 0 8 6 Name ol Person Sealing Well or e ing <br />