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WELL OR BORING LOCATION <br />MINNESOTA DEPARTMENT OF HEALTH SMinnesota ealing Nowell and Boring <br />WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br />H C 73 4 <br />County Name <br />Ae1111l?' 111 <br />Minnesota Statutes, chapter 1031 or W -series No. <br />(Less blankNnal k—) <br />Township Name7 <br />Township No. <br />Range No. <br />Section No. <br />Fraction (sm. - Ig.) <br />Date Sealed <br />Date Well or Boring Constructed <br />Jrono <br />117 <br />23 <br />1 1U <br />N ' LIE <br />- - <br />GPS LOCATION - decimal degrees (to four decimal places) <br />Latitude Longitude <br />Depth at Time of Sealing ft. <br />AO IFER(S) <br />Single Aquifer ❑ Multiaquiler <br />Original Depth ft. <br />STATIC WATER LEVEL <br />Measured Date Measured /0 - �� � � t] Estimated <br />b .2 <br />✓ ft. 19below ❑ above land surface <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />1201 t3 r i ce r .� t �% r O it <br />WELL/BORING <br />,,, <br />Water -Supply Well ❑ Env. Well <br />El Temp. Boring El Other <br />Show exact location of well or boring Sketch map of well or <br />in section grid with "X° location, showing prop <br />N lines, roads, and build <br />oring <br />rty <br />f gs. <br />CASING TYPE(S) <br />t <br />`-----`-- JL! ' <br />Steel El Plastic ❑ Til e ❑ Other <br />WELLHEAD COMPLETION <br />IN <br />Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: Basement Offset <br />t I i <br />I t I 'h Mile <br />' <br />S <br />� <br />F-1 well Pit El Buried Well House <br />❑ Other El wait Pit <br />Buried <br />I Miley <br />For temporary borings, provide additional location <br />information, a site sketch, and geology on a separate page. <br />i <br />❑ Other <br />CASING(S) <br />Diaptgter Depth Set in oversize hole? Annular space Initially grouted? <br />d in. from to;Q3 ft. ❑ Yes ❑ No ❑ Yes ❑ No `Unknown <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />PROPERTY OWNER'S NAMEICOMPANY NAME <br />Property owner's m]aili�ngaddress If dirent than well location address Indicated above <br />104 Gy <br />in. from to ft. ❑ Yes ❑ No El Yes ❑ No ❑Unknown <br />SCJ <br />SCREEWOPEN HOLE <br />.3a <br />WELL OWN R'S NAME/COMPANY NAME <br />Screen from to C� ft. Open Hole from to ft. <br />,O�-BBSTRUCTIONS <br />r'dlods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />Well owner's mailing address if different than property owner's address Indicated above <br />Type of Obstructions (Describe)i►- <br />Obstructions removed? Wes ❑ No Describe <br />PUMP <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TO <br />❑ Not Present Present, Removed Prior to Sealing ❑ Other <br />Type <br />If not known, indicate estimated formation log from nearby well or boring. <br />%) <br />METHOD USI�O SEAL ANN LAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />No Annuiart lace Exists ❑ Annular Space Grouted with Tremae Pipe ❑ Casing Perforation/Removal <br />l <br />Casing Diameter <br />in. from to ft. ❑ Perforated ❑ Removed <br />In. from to ft. ❑ Perforated ❑ Removed <br />Type of Perforator <br />VARIANCE <br />Was a variance granted from the MDH for this well? ❑ Yes Ko TN# <br />GROUTING MATERIAL ) <br />Grouting Material 1^ ^- •fm ! to ft. yards bags <br />from to ft. yards bags <br />from to ft. yards bags <br />OTHER WELLS AND BORINGS <br />Other unsealed and unused well or boring on property? ❑ Yes No How many? <br />LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br />This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The Information contained in this report <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />is true to the best of my knowledge. <br />Don Stodole Well Drilling Co#. Inc. 1091 <br />Licensee Business Name License orrr Registration No. <br />Ctfir ke reseritat e Sigel e` Certified Rep. No. Date <br />, <br />�, ' O`'�"' <br />LOCAL COPY <br />H ? ( 7 4 <br />Name o/ Person Sealing Well or Borlpg <br />HE -01434-17 ID# 53159 <br />