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;.�G4„�.� <br /> ;. ... _ <br /> ,.. < . . < • , , <br /> : wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �4 Q 7 4 9 <br /> � WELL AND BORING SEALING RECORD Sealin No. <br /> Coun Name g <br /> Minnesota Unique Well No. <br /> � i� Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leeve blenk il�al krawn) <br /> � Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Construded <br /> Orcmo I27 3 1 32 1�3 '�� '�� J� <br /> GPS Latitude degrees minutes seconds ` /�, j <br /> LOCATION: Depth Before Sealing ��`-� ft. Original Depth tt. <br /> Longitude degrees minutes sec:onds p �FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City oi Well or Boring Location Single Aquifer ❑Multiaquifer <br /> W LUBORING Measured ❑Estimated <br /> � Water Supply Well ❑Monit.Well r <br /> Show exact location of well or boring Sketch map of weil or boring �'] <br /> in sec[ion grid with"X" I Ape ny ❑Env.Bore Hole ❑Other /� ft. �below ❑above land surface <br /> I es,roads,and buil d'ngs. <br /> - - - -N- -- - -- -.� CASING TYPE(S) <br /> '"�""��-"`"�-"'- � Steel ❑Plastic ❑Tile ❑Other <br /> W -- - -�-- -i-- --�-- E WELLHEADCOMPLETION <br /> Outside: ❑Well House Inslde: ❑Basement Offset <br /> _Y_ ____ _l__ __.�__ � _ _�e .•»— <br /> � �^"b �Ie �PitlessAdaptedUnit ❑WeIIPit <br /> --�- -�-- -�-- --i- I <br /> 1 ❑Well Pit ❑Buried <br /> S J 1' .^� <br /> �_""a'—�' 1i�'1'�.S.i-.. ...`a' ..,,;, c._ ;,.3n ❑euried <br /> PROPER'TYY OW/�N,E.�R'S�NAME/rCOMPANYt,N,�A,�ME��s CASING(S) <br /> �t[Gi3 �a�[L�r .k�� rl� tlbit$ Dia et Depth / Set in oversize hole? Annular space ini[ialty grouted? <br /> Property owner's mailing address if diHerent than well location address indicated above ^��Q <br /> � / <br /> � in.f�om d t0�ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> "�5�—�+7�"'7�Z�i1P_ �StOtt <br /> in.f�Om t0 ft. ❑Yes ❑No ❑Yes ❑Na ❑Unknown <br /> in.f�om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELLOWNER'S NAMEJCOMPANY NAME SCREEWOPEN HOLE <br /> / � <br /> Well owner's mailing address if diHerent than property owner's address indicated above Screen from 10 ft. Open Hole from�t0�ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe)�N�L../� ��� � �V n7� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM 70 Obstructions removed? es ❑ No Describe <br /> FORMATON <br /> If not known,indicate estimated formation log from nearby well or boring PUMP t� <br /> f�l � ; J� TYPe J Ur� �C..>!'� � <br /> � � ' 7�.1 Removed ❑ NotPresent ❑Other <br /> '" l,i���+'�` L �J 7�j/ METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> dlNo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PerforatioNRemoval <br /> !� <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 Ibs.) <br /> / , �Grouting Material��'��f ��-1//=�lf.nm � to S��ft. yards � bags <br /> from to ft. yards bags <br /> trom to R. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes �No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> jf This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> �:�f JF-� ��� � J, ��' � �� . . f true to the best of my knowledge. r <br /> t/ . <br /> ' ; ,, - � >; /�,' / Don Stodola �ell Dcilling Ga, Ir�. 27172 <br /> '� � Conhactor Business Name License or Registration No. <br /> � ���.. ,�.�°�`J ' '�✓ � <br /> Aut z e esenta�ve ignatur,e' . Date <br /> \; }— <br /> Y y-.. <br /> _.�_�; ..1�.--. ,;..1„a.a_Sy s. <br /> LOCAL COPY H � -4 0 7 4 9 Name of Person Sealing Well or Bonng � <br />