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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 31�614 <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. <br /> f��e��� Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave bl�n+il nol known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�ig.) Date Sealed Date Well or Boring Constructed <br /> Qconr� 117 23 07 �F �E � f C� D EC /2 <br /> GPS LOCATION—decimal degrees(to four decimal places) �J � <br /> Depth Before Sealing `� ft. Original Depth ft. <br /> Latitude Longitude <br /> IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location ! _Single Aquifer �_'�,Multiaquifer e�-t� /�� <br /> 4148 Ft�f,�hwnod Rd, Or�o �'/ LUBORING [�vleasured �J Estimated Date Measured Jn mt !J/'�� <br /> �Water-Supply Well [�Monit Well r �/ � <br /> Show exact location of well or boring Sketch map of well or boring �.i • '��]u �above land surface ' <br /> in section grid with"X" location,showing property � ,Env.Bore Hole ��Other__ � ___ tt. L below <br /> N � { lines,roads,and buildings. CASING TYPE(S) <br /> --:._- --�_. ---`-- ---'-- <br /> � �,Steel [;Plastic �,_Tlle �, �,Other <br /> ---- -'-- --- -- ----- WELLHEAD COMPLETION <br /> ' - -I. : : <br /> W __ ET � <br /> �.,. � Outside: ,__j Well House � �At Grade Inside: �asement Ottset <br /> � � � � �� � �� ' I A /� � � uried ��Well Pit <br /> i � <br /> � B <br /> ; ; � � . �,_ �Pit ess dapter nit � <br /> �-- � 5—�- -�-- I�.7� � <br /> , , ; ; '. - . ;Buried ` <br /> �y ��- �j [.�Well Pit �.: <br /> � i Other_ <br /> �-1 Mile-� �.�.�OthBf_ � � � <br /> \ __ <br /> P�{9gERTY�O 9NE NAME�COMPANY NAME CASING(S) <br /> 1"'l�a••"`.' ��Cer Dia te�r� � Depth � Set in over�s�ize/hole? Annular space initially grouted? <br /> Property owners mailing address if ditterent than well location address indicated above ,� jn.from� t0 �� ft. '�Yes �_I{IJo !r]Yes I_'.NO LJ Unknown <br /> P.O. 13osc 763 <br /> •�81Zf�t�n �t�Ay� �, �AT� in.trom_____ to ft. _,Yes '-!No �.'j Yes ❑No ❑Unknown <br /> J <br /> in.irom to ft. 'Yes �__;No Yes ' <br /> ,__. �] ❑No l]Unknown i <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � <br /> i <br /> Well owner's mailing address if different Ihan property owner's address indicated above SCfeen flom� to_ �� ft. Open Hole from to.,__ ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe �_'i Check Valve(s) ❑Debris �,!Fill ❑No Obshuction <br /> Type of Obstructions(Describe) 1��'fI�__ ��r � � �(.��J �T�,✓�j� <br /> GEOLOGICAL MATERIAL COLOR HARDNESSOR FROM TO ObsVuctians removed? �es ;__�No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> � ` YP � <br /> '��'-`� `�`� f�f� f� Removed �Not Present [�Other <br /> r METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: ° <br />- � j�Jo Annular Space Exists �_]Annular Space Grouted with Tremie Pipe `Casing Perforation/Removal <br /> in.from __to ft. �'�Perforated i.�Removed <br /> in.from __ to tt. �L]Perforated [-]Removed <br /> T e o!Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? �._j Yes ❑No TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> ,.�+ g''' r /-�+ <br /> GroutingMaterial�'L��� c.._-�-��-J��from � to /7 fl.___ _ _ yards� bags <br /> _ from____ to ft._______ yards bags <br /> ____ .. ___ from___.___ to_ ft. yards bags <br /> OTHER WEILS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? []Yes �jo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This wetl or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. . <br /> I� Stodala Well Drillin� Co,. Ine. ��,9L__ <br /> Licensee Busin ss Name � - License or Registration No. <br /> � ,- � /� //'-/..3 <br /> ified es�n t e Signa Certilied Rep.No. Date <br /> . ::.. _�..�.. �.�.���'�.�..`�._ <br /> LOCAL COPY H � '� �j`� �� <br /> --—— ...---- <br /> �J� Name ol Person Sealing Well or Boring <br /> HE-01434-14 IC#140-0423 sn3q <br />