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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring z g 9 0 3 0 � WELL OR BORING LOCATION Sealing No. H County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. � �Q Minnesota Statutes, Chapter f03I or W-series No. (Leava blank ii not known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Oro�no i18 23 36 t�l.► SL� N!� 8 F P 4 . . GPS Latitude__, degrees minutes seconds Depth Before Sealing 2�� tt. Original Depth ft. E' LOCATION: Longitude degrees minutes seconds A�UIFER(S) STATIC WATER LEVEL Numerical Sireet Address or Fire Number and City of WeII or Boring Location � Single Aquifer ❑Multiaquifer ,�/� 517 Fect�ale Rd N, vLVIiE,� WELL/BORING I_�easured ❑Estimated Date Measured Sr4,ir�' �� r, . -�, Water-Supply Well ❑Monit.Well r •�. ` Show exact location of well or boring Sketch map of well or b ` �. in section rid with"X." location,showin n Env.Bore Hole ❑Other �� ft. below ; 9 lines,roads,and bui din � — ---- � l�above land surface nl . CASING TYPE(S) " --'-----i-- --`-- ---'- � � � � � �teel ❑Plastic ❑Tile ❑Other . � " '-'--- --'--- ---`-----�-- WELLHEAD COMPLETION - W ; ; ; ; ET � ' ' _;____r__ Outside: ❑Well House []At Grade Inside: i�asement Offse[ �.��A '/,Miie V�„ ', �.pitless Adapter/Unit ❑Buried � ]Well Pit --�----�------�-- --�— i]Buried � ' S ' �Well Pit j .,--�-ry�q_,,,� rl ❑Other _ �--1 Mile f ❑Other PR�OtPE,RfTY OW!NER'S NAME/ MPANY NAME CASING(S) � YClt R Diame � � Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diflerent than well location address indicated above in.from � to ft. i]Yes No Yes �.� [J ❑ ❑No U Unknown 1� Yeit Place in.from to ft ❑ ❑Unknown R�' � �r��k ❑Yes [j No ❑Yes No J Y in.from to ft. ❑Yes ❑No ❑Yes ❑Na '�I Unknown WELL OWNER'S NAMEiCOMPANY NAME SCREEN/OPEN HOLE Well owner's mailing address if ditterent than property owner's address indicated above SCreen from to ft. OpOn Hole from z�3 to �.��ft. OBSTRUCTIONS Rods/Drop Pipe j�Check Valve(s) ❑Debris Lj Fill [.J No Obstruction Type of Obstructions(Describe) �i{/�jC �1/� r ��,�/�f) TJ GEOLOGICAL MATERIAL COLOR HaaoNESs oR pROM TO Obstructions removed? Yes �.J No Describe FORMATION If not known,indicate estimated formation log from nearby well or boring. PUMP �s r� Type�c,��,_�e�j�.t} �"j �� iemoved [_Ji No�resent ❑Other � _ J �....l.-��'F� � ( METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASWGS,OR CASING AND BORE HOLE: ��lo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing PerforatioNRemoval in.from to k. ❑Perforated ❑Removed _ in.from to ft. [�Perforated ❑Removed Type of PeAorator 'r. ' ❑Other _ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) .}� r / Grouting Material IV'��lT��tJ{ from � to� ft._ yards�_ 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 the best of my knowledge. � Stodala We12. D�illing Co. Ic�c. 269i v Licensee Business me � � License or Registration No. ,v--� � �% ' � �'J � , � ; rti d presentative Sh�nature Certilied Rep.No. Date � LOCAL COPY H �9 9 O 3 O ;��'"�Y�'' �� Y`""� Name of Person Sealing Well or Boring � HE-01434-12 IC#740-0423 g�agq T: