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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br />County Name WELL AND BORING SEALING RECORD Minnla <br />eso oUnique Well No, <br />Minnesota Statutes, chapter 1031 or W -series No. <br />7Yonna;'r�n (Lasea�n"aww ) <br />H 388434 <br />Township Name Township No. Range No. Section No. Fraction (sm. Ig.) <br />rano W SW <br />Date Sealed <br />1121 <br />Date Well or Boring Constructed <br />Depth at Time of Sealing ft. <br />AQUIFER(S) <br />Single Aquifer ❑ Multiaquifer <br />Original Depth ft. <br />STATIC WATER LEVEL <br />❑ Measured Date Measured 07/27/2021 ❑ Estimated' <br />ft. ❑ below ❑ above land surface <br />GPS LOCATION — decimaidegrees (to four decimal places) <br />Latitude Longitude <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />e�+ 1 �nrwv /� <br />_ IL.�r+Slflp� ViKid <br />WELUBORING <br />�vl Water -Supply Well ❑ Env. Well <br />1� <br />❑ Temp. Boring ❑ Other <br />S ow exact location of we( b g Sketch map of well or boring <br />in section grid with °X." location, showing property <br />N lines, roads, and buil ings. <br />I I I I <br />CASING TYPES) <br />Steel ❑ Plastic, ❑ Tile ❑ Other <br />--i--- --f-- ---- ---t-- d `��•� <br />W E <br />'h Mile ` �! J� <br />--- --- -- --- - 1 <br />S � <br />{1 Mile i <br />. <br />WELLHEAD COMPLETION <br />Outside: Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset <br />❑ Well Pit ❑ Buried ❑ Well House <br />❑Other E) Well Pit <br />E) Buried ' <br />El Other <br />For temporary borings, provide additional location ti�S <br />information, a site sketch, and geology on a separate page.I <br />CASING(S) <br />Diameter Depth Set in oversize hole? Annular space initially grouted? <br />tt in. from_= to 75 El ft. Yes No Yes No X Unknown <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />PROPERTY OWN'NAME/COMPANY NAME <br />L. ► y� <br />Pirdpppbrty owner's mairing aoare� �f 8 L......_. well iocation address indicated above <br />Udh W xhR <br />tfxzpisior, W. 55331 <br />SCREEWOPEN HOLE <br />Screen from 75'__ to 79' ft. Open Hole from to ft. <br />WELL OWNER'S NAME/COMPANY NAME <br />OBSTRUCTIONS <br />Rod P <br />Drop ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />Well owner's mailing address if different than property owner's address indicated above <br />Type of Obstructions (Describe) <br />Obstructions removed? XYIas ❑ No Describe <br />PUMP <br />❑ Not Present X Present, Removed Prior to Sealing ❑ Other <br />Type -;11 n :i" P_ Y• 9 i D l e <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TO <br />If not known, indicate estimated formation log from nearby well or boring. <br />IMETHOD 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 />-1ri f t <br />1 <br />79 <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 ANo TN# <br />GROUTING MATERIAL(S) <br />n <br />Grouting Material N e a t . 1 a 1Z from_ to�9ft. yards v bags <br />from to ft. yards bags <br />from to ft. yards bags <br />OTHER WELLS AND BORINGS <br />Ocher unsealed and unused well or boring on property? ❑ Yes+'] No How many? <br />LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br />This well or baring was sealed in accordance with Minnesota Rules, Chapter 4725. The information contained in this report <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />is true to the best of my knowledge. <br />non Stodola Uell Drillim So Inc 1691 <br />Licensee Business Name License or Registration No. <br />558 <br />Certified Representative Signature " Certified Rep. No. Date <br />I f <br />LOCAL COPY <br />H}` 8 4 3 4 <br />Name of Person Sealing Well or Boring <br />HE -01434-17 ID# 53159 11/19R <br />