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