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wELL OR BORING LOCAT1oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �3 5 9 3 4 ` <br /> WELL AND BORING SEALING RECORD M nnle oNa Unique Well No. <br /> County Name ; <br /> Hennepf n Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave dank il�wl krwwn) <br /> Township Name Township No. Range No. Seclion No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> OrOQO 117�T 23W 20 �,. �,. �,. Z� /)'l�jY' G?S <br /> GPS t-atitude degrees minutes seconds (� � <br /> LOCATION: Depth Before Sealing 2�� , ft. Original Depth � +� ft. <br /> Longitude degrees minutes seconds pUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �ingle Aquifer ❑Muldaqu'rfer <br /> 275 Carman Rd OY'OItO�.MN. 55331 WEL.UBORING �Measured ❑Estimated <br /> �Water Supply Well ❑Monit.Well i <br /> Show exacl location of well or boring Sketch map of well or boring [f� <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other /� ft. �below ❑above land surface <br /> N lines,roads,and buildi�s. CASING TYPE(S) <br /> �Steel ❑Plastic ❑Tile ❑Other <br /> W --�- -=-- -=-- ----- E � WELLHEAD COMPLETION <br /> � � � � <br /> � �� Outside: <br /> -Y- ---- -�-- --i-- ❑Well House Inside: ❑Basement Offset <br /> � � � � �� �i <br /> � �. � �Pitless Adapter/Unit ❑Well Pit <br /> —�- -�-- -i-- --i— � ' <br /> � S � ❑Well Pit ❑Buried <br /> �—"""°—�" � ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diame er Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if diflerent than well location ad ress indicated above �/ <br /> � in.from� to�ft. ❑Yes �No ❑ves p rvo ❑umcnown <br /> in.frOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.frOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> i � <br /> Well owner's mailing a ress i i eren t an pr perry o e r in SCfeen ffom�to��ft. OpOn Hole from to ft. <br /> P.O. BOX 35 ossTRucnoNs <br /> ` M21 55357 }ea Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> g Loretto, . �, <br /> '�b��t�79..,(�3�� TypeofObstructions(Describe),,,f11.�-XJ� 1�.1� R �J <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 8S ❑ NO Describe <br /> FORMATION <br /> If not kno n,indicate estimated formation log from nearby well or boring PUMP <br /> Type_�1� �tJl/'t� <br /> �.�� � ��� <br /> """' '�Removed ❑ Not Present ❑Other <br /> 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 /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> Type of perforator <br /> , ❑ Other <br /> GROUl1NG MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonfte=50 Ibs.) <br /> /} yry �} r �/� <br /> Grouting Material �Q����t�+t„�!/���from�_to�i.i[. yards �.�,L bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTMER WELLS AND BORINGS <br /> ' REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.TMe information contained in this report is <br /> true ro the best of my knowledge. . - <br /> DON STODA7�A WELL 1��Ti.T.TtaG ��.� ��,J� T, �� <br /> Contractor Busme Name L�cense or�s�a�o��. <br /> ��'�� �-- � ��fJ lr'�.i <br /> horized"Representative Signature Date <br /> \� f''�` <br /> - �... <br /> H 2 3 5�3 4 ��- �:..��.,�V,.,�-�... <br /> LOCAL COPV - - � <br /> Name of Person Sealing Well or Bonng � - � <br />