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: wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �4 Q 7 4 9
� WELL AND BORING SEALING RECORD Sealin No.
Coun Name g
Minnesota Unique Well No.
� i� Minnesota Statutes,Chapter 1031 or W-series No.
(Leeve blenk il�al krawn)
� Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Construded
Orcmo I27 3 1 32 1�3 '�� '�� J�
GPS Latitude degrees minutes seconds ` /�, j
LOCATION: Depth Before Sealing ��`-� ft. Original Depth tt.
Longitude degrees minutes sec:onds p �FER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City oi Well or Boring Location Single Aquifer ❑Multiaquifer
W LUBORING Measured ❑Estimated
� Water Supply Well ❑Monit.Well r
Show exact location of well or boring Sketch map of weil or boring �']
in sec[ion grid with"X" I Ape ny ❑Env.Bore Hole ❑Other /� ft. �below ❑above land surface
I es,roads,and buil d'ngs.
- - - -N- -- - -- -.� CASING TYPE(S)
'"�""��-"`"�-"'- � Steel ❑Plastic ❑Tile ❑Other
W -- - -�-- -i-- --�-- E WELLHEADCOMPLETION
Outside: ❑Well House Inslde: ❑Basement Offset
_Y_ ____ _l__ __.�__ � _ _�e .•»—
� �^"b �Ie �PitlessAdaptedUnit ❑WeIIPit
--�- -�-- -�-- --i- I
1 ❑Well Pit ❑Buried
S J 1' .^�
�_""a'—�' 1i�'1'�.S.i-.. ...`a' ..,,;, c._ ;,.3n ❑euried
PROPER'TYY OW/�N,E.�R'S�NAME/rCOMPANYt,N,�A,�ME��s CASING(S)
�t[Gi3 �a�[L�r .k�� rl� tlbit$ Dia et Depth / Set in oversize hole? Annular space ini[ialty grouted?
Property owner's mailing address if diHerent than well location address indicated above ^��Q
� /
� in.f�om d t0�ft. ❑Yes �No ❑Yes ❑No ❑Unknown
"�5�—�+7�"'7�Z�i1P_ �StOtt
in.f�Om t0 ft. ❑Yes ❑No ❑Yes ❑Na ❑Unknown
in.f�om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELLOWNER'S NAMEJCOMPANY NAME SCREEWOPEN HOLE
/ �
Well owner's mailing address if diHerent than property owner's address indicated above Screen from 10 ft. Open Hole from�t0�ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe)�N�L../� ��� � �V n7�
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM 70 Obstructions removed? es ❑ No Describe
FORMATON
If not known,indicate estimated formation log from nearby well or boring PUMP t�
f�l � ; J� TYPe J Ur� �C..>!'� �
� � ' 7�.1 Removed ❑ NotPresent ❑Other
'" l,i���+'�` L �J 7�j/ METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
dlNo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PerforatioNRemoval
!�
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 Ibs.)
/ , �Grouting Material��'��f ��-1//=�lf.nm � to S��ft. yards � bags
from to ft. yards bags
trom to R. 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
jf This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is
�:�f JF-� ��� � J, ��' � �� . . f true to the best of my knowledge. r
t/ .
' ; ,, - � >; /�,' / Don Stodola �ell Dcilling Ga, Ir�. 27172
'� � Conhactor Business Name License or Registration No.
� ���.. ,�.�°�`J ' '�✓ �
Aut z e esenta�ve ignatur,e' . Date
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_.�_�; ..1�.--. ,;..1„a.a_Sy s.
LOCAL COPY H � -4 0 7 4 9 Name of Person Sealing Well or Bonng �