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MINNESOTA DEPARTMENT OF HEALTH Minnes�ota Well and Boring � �� WELL OR BORING LOCAT�ON Sealin No. H � � �o��,Y��r� � WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Cha ter 1031 or W-series No. u^TA; �n � (L2ave blank�it not knowni ft��taiG �� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �?rono 117 23 �;�� "�" 'v�; i�Il�' J U�F �� GPS LOCATION- decimal degrees(to four decimai places) �.q � Depth Before Sealing �"' � ft. Original Depth ft. Latitude _ _._ Longitude _,_ _ --- FER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and Cit of Well or Borin Location ingle Aquifer ❑Mul�iaquifer Y 9 �--�i�f /� 2450 Countrysi�e �C� ��OTlt1 55356 WELUBORING Measured ❑Estimated DateMeasured_ -j�''�K `.J�� ,�Water-Supply Well ��Monit.Well ` � Show exact location of well or boring Sketch map of well or boring �� in section grid with"X° location,showing property ❑Env.Bore Hole ❑Other _ __ � R. �below ;�above land surface .- � N lines,roads,and buiidings. CASING TYPE(S) --'-----'--- ---`-----'- �.�teel ❑Plastic U Tile ❑Other __. . _ _ --'-----'--- --`"----�-- WELLHEAD COMPLETION ` W ; ; : ; ET ' ' � � Outside: � 'Well House ,_:At Grade Inside: ❑Basement Offset - - ----- -- -- --- -- , , , , � Mile W� �itless Adapter/Unit �J Buried ❑Well Pit '� J� - --.-- --,-- --�-- ---:-- l ❑Buried � S ` .�,Well Pit �� ❑Other �1 Mile—� 'y � �.�OfhBf_ __ .. �-��._' ,v_� �--�..� �..4`. PROPERTY OWNER'S NAME/COMt�PA..N,Y, NAME CASING(S) Lorriane �{��t�.'ti[lu�n Diame �� Depth � Set in oversize hole? Annular space initially grouted? �.l � Property owner's mailing address if different ihan well location address indicated above in.frOm_�__ to�ft � �Yes �lo ❑Yes NO ❑ ❑Unknown in.from to ft. ',Yes U No ❑Yes ��No ❑Unknown in.from to _ft �_]Yes '�I No ❑Yes ❑No ❑Unknawn WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � r Well owner's mailing address it different than properry owner's address indicated above Screen from ��t0 ! �, ft. Open Hole from to _ .._ft. - OBSTRUCTIONS (_�Rods/Drop Pipe �Check Valve(s) �'Debrls ',_,FIII �o Obsiruction Type of Obstructions(Describe) ____ _ ____ _ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? [__.Yes �, i No Describe FORMATION If not nown,indicate estimated formation log from nearby well or boring. PUMP � � ic"1 t TYPe — — � Removed I�Not Present ❑Other f METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �lo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe Casing Perforation/Removal . in.from__ to__. ____ ft. � .��;Perforated �]Removed � in.from_ _ to ft. ❑Perforated ❑Removed Type of Perforator_ VARIANCE Was a variance granted from the MDH for this well? ❑Yes � No TN# GROUTING MATERIAL(S) (One bag of cement=94 bs.,one bag of bentonite=50 Ibs.) ^� M ��J''' / /(� / � �+j Grouting Material ��!'f,/ �/!/F/'v�from Q to / / ft. yards_,_ " "" bags from to R. yards bags __ __ from to_.__.__ fl. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �]Yes �. o How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. I)on Stcxiola �•i Licensee Business Name � . � License or Registration No. � � .i - ,� _ ...�,�- . .�,;."- — , ., � ,�� - /y _ .y - � � ,. , ili R r senta�ive�gnature� Certilied Rep.No. Date LOCALCOPY - � � " 3 2 0 2 71 Name ol Person Sealing Well or Boring f"' \�� HE-01434-14 IC#140-0423 � ;" Si�sR