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� - <br /> il MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring � 5 3 3 6 2 <br /> ' �WELL OR BORING LOCATIO�J Sealing No. "' <br /> �o��,Y Name - WELL AND BORING SEALING RECORD Minnesota Unique Well No <br /> � i� Minnesota Statutes, Chapter 1031 °edW series No. <br /> Township Name Township No. Range No. SecP�on No. Fraction(sm.�IgJ Date Sealed Date Well or Boring Constructed <br /> Orc�no 18 2 36 '' '' '' OC <br /> GPS Latitude degrees minutes seconds Depth Before Sealing_�' ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes____ seconds �FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> ' n1 LL/BORING � Measured ❑Estimated Date Measured " <br /> 75 Fernda2e t[Ci �� Or�1� 55391 Wa,e,-S�PP,Y We„ � �Monit.Well . <br /> Show exac[location of well or boring Sketch map ot well or �-, / <br /> in section grid with"X° location,showing prop y�. '�U Env.Bore Hole ,_;Other �7Z __ft. elow ❑above land surface <br /> N lines,roads,and buildi CASING TYPE(S) <br /> -- --- ------ --- -- ----- 1 � Steel ❑Plastic [�Tile ❑Other <br /> � � � . <br /> ( <br /> � WELLHEAD COMPLETION <br /> W ; ; : : ET � <br /> � � � � Outside: ❑Well House []At Grade Inside: �'Basement Offset � <br /> 'h n4iie '1 Buried ❑Well Pit <br /> ' --�-----T-- ---�-- ---�-- itless A p dUrnt d <br /> 1 ❑P da te <br /> ❑Well Pit ❑Burie <br /> S ❑Other <br /> �1 Mile� � ❑Other <br /> } <br /> ' PROPjERTY OWNLEfR'S.N�AfM�E/�C,O�MPANY NAME 'G SING(S) <br /> Cl Dr�liR�lfi,4�,1 952-404-Ob76 DiarrLetef� . Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above 3 in.from � to_1�Q ft �_,�Yes �No ❑Yes ❑No ❑Unknown <br /> � ����1� � " in.from to R [.�Yes j�No ❑Yes �,_;No ❑Unknown <br /> Oro�no, MN 55391 <br /> in.from to R U Yes ��No []Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � <br /> 1 <br /> t <br /> Well owner's mailing address if diKerent than property owrer's address indicated above SCfeen ffom__��f_�_to�ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe �.;,�Check Valve(s) ❑Debris ❑Fill rJ No Obstruction k <br /> Type ot Obstructions(Describe���(��lC �T�� R f f-' T <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �es �No Describe <br /> FORMATION �n <br /> PUMP <br /> If not �own,indicate estimated formation log from nearby well or boring. M <br /> /�-� ��.� !r7 I TYPe��/_C' � �tJ r��D ���, <br /> Removed i`j Not PreseM ❑Other <br /> a <br /> 5 <br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HO : <br /> � o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing erforation/Removal <br /> in.from_ to ft. ❑Perfor ed ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other � ���g <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) - <br /> T / <br /> GroutingMaterial/V�1 � Jr from� f toL��ft._ yards� bags <br /> _____ __ _ from __ _ ro ft. yards_ bags <br /> ___ from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES iN SEALING Other unsealed and unused well or boring on property? ❑Yes �� o How many? _ <br /> LICENSED OR RFGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The iniormation contained in this report � <br /> is true to the best of my knowledge. <br /> Ddn Stodola WeII Dcilling Co., Inc. 1641 <br /> Contractor Business Name License or Registration No. <br /> .� /� �J �� <br /> / <br /> iii resentat ve Signatu�e-- Certified Rep.No. Date <br /> g <br /> H �``. f �1 vi.1J.f!`��'" <br /> LOCAL COPY 2 5 3 3 6 2 \ <br /> Name of Person Sealing Well or Boring . <br /> HE-01434-09 IC#140-0423 " s/osR <br />