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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 7 4 4 4 4 County Name WEL�. AND BORING SEALING RECORD Mennleso a�Unique Well No. Minnesota Statutes,Chapter f03J or W-series No. Aenn «ea�e b�a�k��o,k�ow�, Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed '' 2�' O�-T /� Q , GPS Latitude degrees___ minutes____ seconds Depth Before Sealing �CO�l ft. Original Depth_ tt. LOCATION: Longitude degrees___ minutes seconds �- - A FER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location � ingle Aquifer []Multiaquifer �/ M �.�y /^�� E BORING 'l�uleasured ❑Estimated Date Measured ��//'� (.)/'7 __ 1�5 `^r++�-v��8 �J� Qr(�'(� � 3 Z �Va�ter-Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or oring �/ in section grid with"X:' location,showing pro rty �Env.Bore Hole ❑Other �t ft. '�below ❑above land surface � lines,roads,and buil / N 95� CASING TYPE(S) --'--- --'-----`- --'- yt �� � ;�teel ❑Plastic ;]Tile ❑Other "�"'-'�"'---`-- ---`-- WELLHEAD COMPLETION W : : ; � ET � � � � _ Outside: i_;Well House ❑At Grade Inside: [�sement Offset � 'h M'ie ❑Pitless Adapter/Unit ❑Buried ❑Well Pit --:--- --r-----�-- ---:-- 1 ❑Buried ' S ' ❑Well Pit ❑Other ��Mile� ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) � � Diamet f� ' Depth� Set in oversize hole? Annular space initially grouted? Pioperty owner's mailin a ress if different than well location address indicated above �in.frOm � to�fl. ❑Yes 1l0 �.�]Yes [�No ��1 UnknoWn in.from ta fl. ❑Yes ❑No ❑Yes �No ❑Unknown _in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE t // /y/y� ► Well owner's mailing address iF diflerent ihan property owner's address indicated above Scfeen from to ft. Open Hole from_! L�!'� to /`��./ fl. � OBSTRUCTIONS ,�ods/Drop Pipe '�!Check Valve(s) ❑Debris ��]Fill , ��,No ObsVuction Type of Obstructions(Describe)_ ..l 1V/V�J` �;,�� /� ��/`r GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? I�s f]No Describe FORMATION PUMP If not kn wn,indicate estimated formation log from nearby well or boring. T e �� u m r..l�i �� YP �" emoved [�]Not� ❑Other )' _ �•+�:�� --� �.,,,_j .J..J1if3_�L. M�OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING#ND BORE HOLE: - ,/�I I i � [ o Annular Space Exists �,_,I Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Fiemoval Ep (p in.from io ft:. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator � , ..:.. . .; .;. , ....,..�_.._ Oth � , .. - . . .. , . ��. B ,_ . ._ :.. ... .. ..._ .,.... . , ,. :. GROUTING MATERIAL(S)' � � (One bag of cement-=94 Ib�.,one bag of bentgnite=50 Ibs.) �r, =- . , ,. . .Grouting.Material /v�� `�'""-1r�rii � to�"�_�__ yards /� ba s g 9 ' from to ft. yards_.__ _ ._ bags . � _ ____ _ from to .__ ft. yards bags � . . .. . ... . . . . . .. .. .. . ' ` ..: .. . ... . .. .OTHER��WELLS AND.BORINGS `: REMARKS,SOURCE OF DATA,DIFPICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes I �'� How many? ". � � � � �� "�""'�� LICEN3ED OR REGISTERED�G.ONTRACTOR CERTIFICATION.. �" This well or boring was sealed in accordance with Minnesota Rulgs,Chapter 4725.The information contained in this report is true to the best of my knowledge. � � . " '� : l�an Seodola «e1I Drillin�Co., Inc. 1b91 :° �� '�- � � � � ��-�^ �� -�-�� .. Licensee Bus;n�ss Name � � �+"'� License or Registration No. � . :_.:. . . . �. ' . . . � .., .; . . :. �J �1 �� ..: � . � „_� : Ce e e resentahve Sigii re � GeKi/ied Rep.No. , Date r -- -------- � . _ , u 274444 w � Y��,,,-�.- � ,�P.L.COPY n Name ol Person Sealing Well or Bori ____ _ ---- - �_ HE-01434-11 IC#�140-0423'-.... .... . ... .. . .. .. . .. _ ... ..,:, . 2/oea