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V- MINNESOT EPARTMENT OF HFALTH Minnesota Well and Boring
WELL OR BORING LOCATION �yELL A ORING SEALING RECORD Sealing No. �H �,���6�„ �
Counry Name Minnesota Unique Well No. I --
�QnQp�� Minnesota Statutes,Chapter 1031 or W-series Na � �
(L�ev�deM rc na knvxn)
Township Name Township No. nge No. S ion No. Faction�sm.-i Ig� Date Se ate�Well or Bonng Constructed
`` 7 21 3��(3�2 �-.
2.� f� 0 4
�yu/e/�nc/a�l ireet Atldress o�Fi N er nd tv of Well or Bonng-Location 1 ' -7'` r
G S,�Ctl,� ��Q$$$n fiLl� ����� �`�,�j��� oth Before Sealing ��`` ft. Original Depth . `-v i� n.
Show exact Iceation of well or borin Sketch map of well or bonng AQUIFER(S) STATIC WATER LEVEL
i locahon, sAo ing property Single Ayuder � Multiaquifer
i lin roa s,� d buildin s �/
ry '`�,`-����-+>>r"y--�-"��� �� �`�-� 9 WELL/BORING J�J`Measured ❑ Estimated
Water Supply Well ❑Monit.Well /-� �
❑ Env Bore Hole ❑Other _ �R. �below ❑above land surtace
W --�" '�-- -�-- --'-- E CASING TYPE�S)
� � � ��� �
� � �
-�-- -;-- -r- --;— � i � �Steel � Plastic �Tile � Other
� � � � Y�mile -�j- �
-�-- -i— -�-- --1-- � � CASING(S)
Dlameter Depth � Set in oversize hole7 Annular space initiaily grouted?
S ��_.1-•-�----s.-.� `,,,) /, � � 1�
��m�� in.from to R. ❑ Yes o ❑ �es ❑No ❑ Unknown
PROPERTV OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
Properry owne�s mai ing address if dAferent than well IocaBon address intlicated above. in.from to R. ❑ Yes ❑No ❑ Yes ❑No n
.�S�IEa$S SbOV� SCREEWOPENHOLE r `
Screen from � ro� ft. Open Hole from to k.
OBSTRUCTIONS
WELI OWNER'S NAME ❑ Rods/Dro Pi
p pe ❑ Check Valve(s) ❑ Debris ❑ Fill No Obstruction
Well owners mailing address if diMerent than property owner's address indicated above. Type ot Obstructions(DesCribB)
Obstruclions removed? ❑Yes ❑ No Describe
PUMP
Type
OEOLO(i1CAL MATERIAL COLOR MARDNESS OF FROM TO � Removed �Not Present ❑ Other
FORMATION
N rat krawn,indicate estimeted fortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space Exists
d ❑Annular space grouted with tremie pipe
❑Casing PerforaHon/Removal
in.f�om to R. ❑ Perforated ❑ Rertroved
in.irom to n. ❑ PeAorated ❑ Removed
Type ot peAorator
❑ Omer
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
_ �
GroutingMaterial����`-�/����f/om y,,,L� ro �� k. yards �Z bags
from to tt. yards bags
trom to ft. yards bags
from to__ tt. yards bags
REMARKS,SOURCE OF DATA,dFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
'-'(_. /. i.
�� � � This well or bonng was sealed in accordance with Minnesota Rules,Chapter 4725. The informalion contained in this report is
�' �QO� true to the best of my knowledge.
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' Don�Stodola We1lDrillin Ca. Inc. 27I72
� Contractor Business Name License a Regisbafion 170.
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! �-�<,. - �-29-0
A o' resentafive SignaN _ �ete
Ji� �ntQnson
LOCAL CO�Y H �7,���y�� Name ol Person Sea�ing Well a Bonng
B� V