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� � �T WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I'„� �C��(�� County Name WELL AND BORING SEALING RECORD Mlnnle90 a�Unique Well No. J �� Minnesota Statutes,Cha ter 103I or W-series No. P (Leave blank if not knownj Township Name Township No. ange No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed / / ! �p `!�l � lJ i, i GPS Latitude____ degrees.___ minutes seconds Depth Before Sealing �� _ft. Original Depth ft. �' LOCATION: Longitude_ degrees_ minutes seconds UIPER(S) STATIC WATER LEVEL �I�� Numerical Street Address or Fire Number and City of Well or Boring Location ._ Single Aquifer ❑Multiaquifer �nly�f q/) �,/ � W LUBORING �Measured I�Estimated Date Measure /y l �Jl"'��_ ��,: 2545 D1iAMOOd ��ipply Well [,,Mo��c.weu "/ ' Show exact location of well or boring Sketch map of well o bo� � .-� y in section grid with'�X" location,showing pro ert 'Env.Bore Hole j_Other / � ft. �1 below ❑above land surface N lines,roads,and buil � CASING TYPE(S) �. � --'--- --�-- ---`—---'-- .. ,Steel ❑Plastic ��Tile ��Other � � � � � � � � -- --- ------ -------- -- ELLHEAD COMPLETION � � � . W ; ; ; ; ET y., � , . , _� � _;____;_ �-• Outside: �_�Well House �At Grade Inside: ❑Basement Offset --,-- ---�-- - d ':� , , , , �Mile dless A p r/Unrt ❑Buried ❑Well Pit , , , , �. � ❑P da te , , , � —�-- --�----�- ❑Burie �Well Pit S ❑Other F-7 Mile� ��' ❑Other_ PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Dia e�j � Depth : Set in oversize hole? Annular space initially grouted? Properry owner's malling address if i terent than we I a ion a ress indicated above �in.from_�� to_�'�i__ft. ❑Yes �No ❑Yes [i'No [�Unknown I " 7Sf.�471�7885 in.from to ft. ❑Yes ❑No ❑Yes ❑No []Unknow.n �{j � in.from_ to ft. ��Yes ❑No ❑Yes ❑No ❑Unknown - WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � / Well owner's mailing address if different than properry owner's address indicated above Screen from��to /UD ft. Open Hole from to ft. OBSTRUCTIONS Rods/Drop Pipe ❑Check Valve(s) ❑Debris �]Fill �']No Obstruction Type of Obstructions(Describe)�/JMti� ��.�� /(J�U �..r - _" �/ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe ' FORMATION PUMP � If not known,indicate estimated formation log from nearby well or boring. s M` C..J I� Type J��J �� /Y1 � Removed f_]Not resent ❑Other METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated [J Removed in.from to ft. ❑Pertorated ❑Removed Type of Pertorator ❑Other_ _ • GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) s Grouting Material/U��J�i4/��L//from� to�_�_ ft. yards_�j_ bags 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 well 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 Ihe best of my knowledge. J C�-r"f I DOI�i STODt)Ll�i i�IBLL DxILLING CO. ,. IN��.�L Contracro�Business ame � . �..- License or Registration No. ;� - -_ �1_ �=� _ � � er_ 'd epreseniative Signature= Certified Rep.No Date LOCAL COPY H �V V'7,�� /�''i"^- `'.� —"��Y�IS�f�"� _-____ Name of Person Sealing Wel/or Boring HE-01434-09 IC#140-0423 s/osR