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MINNESOTA DEPAFTMENT OF HFALTH M�nnesola Well and Bonng � �
WELL OR BORING LOCATION yyELL AND BORING SEALING RECORD Sea�ing No. H �5�Q-._j �
County Name Minnesota Unique No. � �
Mmnesota Stalutes.Chapter 1031 or W-series No.
Hc�nnep i n 0.eave biank d no�knownl
Township Name Township No. Range No. Section No. Fracaon�sm.-s Ig.) Date Sealed Date Well or Bonng Constructed
4rono 117 23 2I 2�--0�40� /(a ,f Ur� �j-`r'j
Numerical Street Address or Fire Number and City of Well or Bormg Location t
2 !60 Shady�roo8 R�t�d� QXOnO Depth Before Sealing � n. Original Depth � h
Show exact location of��ell or bormg g�3�1 Sketch map of well or bonng UIFER(S) STATIC WATER LEVEL
in section grid with"X". location, s�owing pioperty Single Aywfer ❑ Multiaq ifer
Gnes,roads,and buildings.
N � "" WELUBORING �Measured ❑ Estimated
��- i r Water Supply Well ❑Monit.Well� t
{? ❑ Env.Bore Hole ❑Other _ C�� fl. �below ❑ above land suAace
� � `� t
W --i-- - -- -i— --i-- E � � CASING TYPE�S)
�
�
� � t� � � � �T ,
-�- —�- -i— --�-- � ��� l� Steel � Plastic �Tile �Other
� � � � F mde�... •`)�
__�_ _�__ � - CASING
-1-- --�-- ��
'� Diameter Depth � f Set in overslze hole7 Annualar space initlally grouted?
S �� �
��,�,�� , -��, in.trom � to � ft. ❑ Yes No ❑ Yes ❑No ❑ Unknown
{
PROPERTV OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ �es ❑ No ❑ Unknown
,��- Q 47I-�e�a
� Properry owner'S mailing a0tlress B dilferem than well locauon address indicated above. in.from to R. ❑ �es ❑No ❑ �es ❑No ❑ Unknown
SCREEWOPEN HOLE ' � / !
Screen from �� to � • fl. Open Hole from ro R.
OBSTRUCTIONS
WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ II ❑ No Obstructi��!.
Well owne/s meilirp address it diflerent then property owner's address Indicated above. Type of ObslruCtions(DesCribB) ���`^-� �� � �`� --
Obstructions removed? �es ❑ No Describe
PUMP ..._
Ty� J�T �'u tYl f
6EOLOfi1CAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Othe�
FORMATION
If not krawn,indicate estimeted tormation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
_� P �No Annular Space Exists
f � f� '�J �t� ❑Annular space grouted with tremie pipe
� ❑ Casing Perforation/Removal
in.from to ft. ❑ Pertorated ❑ Removed
in.from to n. ❑ PeAorated ❑ Removed
Type of perforalor
❑ Other
GROUTING MATERIAL�S)
,�"y�� /
c Grouting Matenal r`��/`�'/ ��Trom � to " " fl. yerds � bags
from to fl. yards bags
from to ft. yards begs
from to_— ft. yards bags
REMARKS,SOURCE OP DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes No How many?
LICENSED Op 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 ot my knowledge.
Don Sto�ola W�il Drilling Ca. , Inc. 27272__ _ _
Contractor Business Name License or Repistration fJo.
f _ ." > /
/f s� J'¢/
/ / ' � ��ni�'C^/����EM`�^�'�'.� /f� � � � �/
.�.._`: �'. ,%f'.
!/�/ 1+'/� -� f �Ts'.i
�presentative Signeture Date
�` ., _../1��, ../l_.�_� �"-.._..,v"�...r•
H � Name ol Pe Seeling Well or Bonng
LOCALCOPY
HE-01434-04 8/98 R