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` wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„' � ; <br /> Counry Name <br /> WELL AND BORING SEALING RECORD MennlegoNa Unique Well No. s <br /> H�C!?� �n Minnesota Statutes,Chapter 1031 or W-series No. <br /> (�eave blank�il not known) <br />� Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Consiructed <br /> Orvno 117 23 18 1 -flQEX;� Q <br /> GPS Latitude degrees minutes seconds '� � <br /> LOCATION: Depth Before Sealing ft. Original Depth_ ft. <br /> Longitude degrees minu�es seconds qQUIFER(S) STATIC WATER LEVEL <br /> `� Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> E L/BORING �easured ❑ Estimated <br /> � Water Supply Well ❑Monit Well / <br /> Show exact location of well or boring SkePch map of well or boring �/> <br /> in section grid with"X" � , � roperty ❑ Env.Bore Hole ❑Other __��ft.�below ❑above land surtace <br /> N �•�lines,roads,and uild}nxg`s.' CASING TYPE(S) <br /> �teel ❑Plastic ❑Tile ❑Other <br /> W -- - - -- - -- -- — E WELLHEAD COMPLETION <br /> , , <br /> ; r , � � � i � Outside: ❑Well House Inside:�Basement Offset � <br /> -�-- -�- -;-- --�-- E �� :; <br /> Ylmile � ❑ Piiless AdaptedUnit ❑Well Pit <br /> '--- -i-' -1-- --�— � <br /> ❑Well Pit ❑Buried <br /> S <br /> �---"""° ❑Buried <br /> �� �� � . �: _a_�T_ .= ' �-',� <br /> �. PROPERTY OWN2E�R,'S NAME/COM Y NAME� CASING(S) <br /> � iNi 952-471-9396 Diamete� � � Depth �� � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than wen location address indicated above � / <br /> � in.from t0 ft. ❑Yes Il�1Vo ❑Yes ❑ No ❑ Unknown <br /> �� <br /> , <br /> - in.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 4 <br /> in.f�om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> '� WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � _ <br /> / <br /> Well owner's mailing address it diflerent than property owner's address indic2ted above Screen from � YO�ft. Open.Hole from_ to ft. <br /> OBS RUCTIONS <br /> �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) �"�"`-'� ���� ¢ ���T��`� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? eS ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated formation log fwm nearby well or boring PUMP <br /> T e <br /> � �.:..� ::, `,j((� YP <br /> ❑ Removed �lot Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No 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 /> rV� Type of perforator <br /> ❑ Other <br /> � �TlrO GROUTING MA7ERIAL(S) (One bag of cement=94 Ibs.,o/ne°ybag of�ntonite=50 Ibs.) <br /> QA, Grouting Material tN �T C���"—�Trom�to�..l3Q_ri. yards � bags <br /> •� <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALWG 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,Chapter 4725.The information contained in this report is <br /> true to the best ot my knowledge. <br /> I1on Stodola �ell Drilling Co,. Inc. 27172 ' <br /> Contractor Business Name License or Registration No. <br /> a <br /> —�i'��Y—�--�'�"'� �,:. _ 1 � ..:i <br /> � Authorized Repr sentative Signature Date . <br /> ��`....��, s <br /> //�/�//� //� ` �i'-yy-._, ���,�,�;y'1�..4J'd1''�- <br /> LOCAL COPY �7 i�L f��f�� Name o/Person Sealing Well or Boring . � <br />