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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota <br /> toN Well and Boring H 400061 <br /> SealingCo ty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,chapter 1031 or W-series No. <br /> EA EF I (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-lg.) Date Sealed 2 <br /> RJ Date Well or Boring Constructed <br /> 'O O 118 23 3 ? SWSWSW'/4 / .i <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 133 ft. Original Depth ft. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location 1]Single Aquifer ❑Multiaquifer / / <br /> 15 nY RTL O0 RD. , g- O N fez• WELL/BORING �]Measured Date Measured 4 L 2 1 f 2 ❑Estimated <br /> i1 V�# +4! 4# 1:1 Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring 5539 1 Sketch map of well boring 69 <br /> in section grid with"X." showing pr erty ❑Temp.Boring ❑Other ft. ]below ❑above land surface <br /> lines,r ds,and bui s.N CASING TYPE(S) <br /> u <br /> X Steel ❑Plastic ❑Tile ❑Other <br /> ----- -----------I---I--- WELLHEAD COMPLETION <br /> w E T• <br /> -- I Outside: ❑Pitless Adapter/Unit Li At Grade Inside: El Basement Offset <br /> h Mile ❑Well Pit -Buried ❑Well House <br /> ---I- - <br /> --- ❑Well Pit <br /> 1 ❑Other <br /> s ❑Buried <br /> 1 Mile <br /> VV. ❑Other <br /> aldkl For temporary borings,provide additA )V N)) . CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> P. O ERT. WNER'S NAME/COMPANY NAME 4 1 to 129 ft,� ,t,' in.from ❑Yes ❑No ❑Yes ❑No �]Unknown <br /> Property owner's mailing address if different well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEN/OPEN HOLE <br /> Screen from to ft. Open Hole from to ft. <br /> WELL OWNER'S NAME/COMPANY NAME <br /> T/C AiOL UNGS OF t ,AINE LLC OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above X Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> 13501 BALSAME LA Type of Obstructions(Describe) DROP PIPE <br /> DA a ON, MN. '"55327 <br /> Obstructions removed? X Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present ®Present,Removed Prior to Sealing ❑Other <br /> FORMATION ❑ <br /> If not known,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE <br /> DRIFT 1 133 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <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 g No TN# <br /> GROUTING MATERIAL(S)NEAT CEMENT 1 133 10 <br /> Grouting Material from 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 41 No How many? <br /> LICENSED OR REGISTERED CONTR/iCTOR CERTIFICATION <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the <br /> best of my knowledge. �roa <br /> DON STODOLA WELL DRILLING CO. ,I C* 1691 . <br /> Licensee Rusin s ame License or Registration No. <br /> 558 4/21/23 <br /> e e Representative Signature Certified Rep.No. Date <br /> LOCAL COPY H 400061 JERKY BARK <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />