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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I '� � '`�� � `�
County Name
WELL AND BORING SEALING RECORD Mennle90 aoUnique Well No. ,,� �`
Minnesota Statutes, Chapter 1031 or W-series No.
�'enne in ��e�,ao�a�k,��a,k�ow�,
. Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
4cono lI8 23 3& '� NF S"� /.�'
GPS LOCATION- decimal degrees(to four decimal places) �
Depth Before Sealing_ � ft. Original Depth_ ft.
Latitude_________._ Longitude -----
�IFER(S) STATIC WATER LEVEL C�-� pF OR
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer I_j Multiaquifer �1
WELUBORING Measured ��Estimated Date Measured ,ri^�3L � �
i�i C!�evq Bhase nc, �LOC14 55�91 - Water-Su I Well •
� PP Y u Monit.Well �!7
Show exact location of well or boring Sketch map of well or boring � � - ,�( �t. �below 1-!above land surface �
�. in section grid with"X" location,shqwing property Env.Bore Hole ��__;Other _ ,__ ;
(� lines,roac�`+amd buildings.
N � _.� .._�. ,r�.F�� CASINGTYPE(S)
�
.. --'--- --'--- ---`-- ---'- �' -
� Steel ��Plastic '._Tile �_',Other ____
--'--- --'--- ---`- ---`- WELLHEAD COMPLETION
= W ; : _ ; ET �-.---
.., __;_ _ _;_ ;_ _ �__ Outside: ��_J Well House �,_1 At Grade Inside: y�8asement Offset `
'h Miie '�]Buried i._.i Well Pit
� [�Pitless Adapter/Unit -
j Buried
___j Weli Pit
� , S f 1 I_I Other_ ��
' �i Mile� ,�yQ-� _]Other_ - � � '
t P^ROwPERTY OWNER'S NAME!COMPANY NAME CASING(S)
t�tl�th ��� Dia eter Depth � Set in oversize hole? Annular space initialiy grouted?
Prope.rty owners mailing address if different ihan well location address indicated above �� / --� -
�_ in.from��� to l.� ft �j Yes �No [_'Yes [��No [;Unknown
. __,_in.from to ft. �,_,'Yes �_ �.No I ;Yes � J No �]Unknown
in.fram to _ft ❑Yes [I No � _Yes � ,No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE �
� , f
� Well owner�s malling address If dltierent than property owner's address indicated above SCreen from1�� to�7_ ft. Open Hole ffOm to_ ft.
OBSTRUCTIONS
RodsiDrop Pipe [��Check Valve(s) I ,Debris ���Fi�l I 'No Obstruction
i /�( "
"- Type of Obstructions(Describe) ��n _�/�%.__¢ �� _ '
GEOLOGICAL MATERIAL COLOR HAHDNESS OR FROM TO Obstructions removed? �Yes I_i No Describe
FORMATION - — - ——---
; PUMP�„ ��:
If not known,indicate estimated formation log from nearby well or boring. +�..�- �'l���—
V ��C TYPe �,7 - � --------- —
���Removed i�i Not Present ���Other..__._ .. . _
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space Exists '� �Annular Space Grouted with Tremie Pipe ���I Casing Perforation/Removal
- in.from to_ _ __ fL ��Perforated ���Removed ��
in.from to_ ft. �_j Perforated � �Removed � � .
Type of Perforator .
VARIANCE
Was a variance granted from the MDH for this well? , �_Yes No TN#____,___
� GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
�}}► �r'� / f
Grouting Material��/yL����� from_CL'_' to.��_ ft._._ _ __ yardsy� bags
trom_,__ to_ ft. yards bags
> --— -- trom -- to ---- ft,---- - Yards— --- bags
OTHER WELLS AND BORINGS
REMAHKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? I. :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.
7
l�arn Stodol.a i�tel� �rillin�; Co,. In�c. 1b91
> — - — — —— - — __-- -- _- _ ---- _
Licensee Business Name � �-�� � License or Reg�stration No.
' / � ..
" ._.�- i - ."`-
, �
' - _ ._ .- .�'_--_. �-�_�-��. .-.._-.__. �
�� Ce � rta tv � nalure;- .�� = -' Certilied Rep.No. Date ;.
a �� ��Y .-.�,�t7'Yti
? LOCAL COPY --— — _._ — ---- -- -� --_ — i
" 3 3 31�1 Name of Person Sealing Well or Boring ��^�
HE-01434-14 IC#140-0423 5.��3R