2012- well & boring sealing record

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` MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �O��} �C � WELL OR BORING LOCATION Sealing No. H j, �,� County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Cha ter 1031 or W-series No. �@IIYi��31 p ��ea�e e�a�k n�o�k�ow�, Township Name Township No. Range No. Section No. Fraction(sm.—�Ig.) Date Sealed Date Well or Boring Constructed h' Ozono 11? 23 20 �W �E�� E � � � GPS Latitude ___ degrees minutes seconds Dep efore Sealing �_�__ft. Original Depih R ��:. LOCATION: Longitude degrees minutes seconds ' AQ IFER ) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ` �Multiaquifer ��7 WELLiBORING �leasured ❑Estimated Date Measured_a�� _ 3165 C.d$�.`Q C..irK.'1@ �rOt10�. �aa�• �yater-SupplyYsJell nMoniLWell / Show exact location of well or boring Sketch map of well or boring � "�; . _ in section grid with"X." ,�-�� location,showi pro(�erty Env.Bore Hole �� '�Other _ �__ft ��below , ';above land surface N � , lines,roads,�builtlilos. CASING TYPE(S) � i�._L,J" , -- �..._J._..� ' '� 'ySteel ❑Plastic ]T�I �[!Other __ ______ __ �� , � � �� :: " --'-----`-- ---�-- ---�-- WELLHEAD COMPLETION � = W ; ; : ; ET ' � � _�__ __ ;_ � utside _,�Well House ❑At Grade Inside: ❑Basement Offset � F'" o ' : --- `' � 'h Miie � �� ❑Buried ❑Well Pit � �. �'� �itlessAdapter/Unit \� � ❑Buried ' T S ' ' ., l4Y :]Well Pit �1 Mile—� �/ �,/ ❑Other ❑Other � PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) " Diameter � Depth � Set in oversize hole? Annular space initially grouted? >� Property owner's mailing address i di eren than we location address indicated above 1� �_in.from$ to��ft. ❑Yes '�lo ❑Yes ❑No ❑Unknown 64n7 Way zata BIYC�• in.irom _ to ft. ❑Yes J No ❑Yes ❑No ❑Unknown M�.ls. ,. KN. 554Zb in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY N E SCREEN/OPEN HOLE � . � t Well owner�s mailing address it diNerent than propeny owner's address indicated above Screen irom__2,t��to��ft. Open Hole from to _ft. � i OBSTRUCTIONS � ��Flods/Drop Pipe ❑Check Valve(s) [Debris '��Fill ❑No Obstruction Type of Obstructions(Describe) ��iC1iG �H_' � � � GEOLOGICAL MATERIAL COLOH HARDNESS OR FROM TO Obstructions removed? ' Yes �]No Describe FORMATION --------- PUMP If not known,indicate estimated formation log from nearby well or boring. Q - .. . TYPe_�p �� f�" � �� emoved �_Not P sent ❑Other � r METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE: o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed c in.from to ft. ❑Perforated ❑Removed Type of Perforator ❑Other , GROUTING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material �/��T�,L��IRom�_ to_��ft. yards� bags from to ft. yards___ bags from to ft. 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 CONTRACTOA�CERTIFICATION � � � � This well or boring was sealed in accordance with�Minnesota Rules,Chapter 4725.The iriformation contained in this report is true to the best of my knowledge. � �� Dt?N STODOLA WELL DRILI.ING CO. .. INC. Ib91 Licensee Business Nam � License or Registration No. � 5.58 �-✓��i - f.,� . � - --- Cer� ep e a i Sig e Certified F)ep.No. Date k ��rJ 1.7 r3 ��-, � ;��.�.,,, .�„ ..,-�,..a�--,..., LOCALCOPY H L Name of Person Sealing Well or Boring � HE-01434-72 IC#140-0423 s/osR �� ..,.. _.. �