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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and eoring H �O�Z�O <br /> County Name <br /> WELLAND BORING SEALING RECORD MnnlesoaoUniqueWellNo. <br /> Minnesota Statutes,Cha/�ter 1031 or W-series No. <br /> �� �"' (Leave blank il no�knOwnl <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Orano 117 23 20 NS NW 1� Z <br /> p . <br /> GPS Latitude degrees minutes seconds Depth Before Sealing �p ft. Original Depth ft. <br /> LOCATION: Longitude degrees _ minutes seconds A UIFER(S) STA71C WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location . ingle Aquifer �Multiaquifer t! <br /> WELUBORING I�leasured ❑Estimated Date Measured �lTf/� Q/9� <br /> � �Nater-Supply Well ;J Monit.Well /� . <br /> Show exact location o wel or boring Sketc of well or boring /Z• h. '`',��..below ' <br /> in section grid with"X." lo n,s wing property Env Bore Hole �]Other __ ;�above land surface <br /> N \ es.roads, nd buildings. CASWG TYPE(S) � <br /> � � <br /> s <br /> --'----�— --`-- '_''- .. <br /> �.�teel . �;Plastic r Tile �_;Other ___ <br /> W __ _________ ' ' _ E /S� <br /> WELLHEAD COMPLETION <br /> __�_____;____;__ ___;_ � �y Outside: [�;Well House ❑At Grade Inside: ❑Basement Offset <br /> �M� L� ��itless Adapter/Unit ��Buried ❑Well Pit <br /> , , , , 1 <br /> --�-----�--- ---�-- --�— ❑Buried �' <br /> 5 � ;Well Pit <br /> �v ❑Other <br /> F--1 Mife� �� � .,Other <br /> PRO�PE`RT�Y OWN*E�R'S.,.N�A,ME'COMPANY NAME CASING(S) <br /> uLi1t� t�CwL{M Diam ter Depth ' Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address it ditterent than well location address indicated above +•in.from_� to��ft. ❑Y@5 [�Jo ❑Yes ❑NO ❑UnknoWn <br /> in.from to ft. ❑Yes '_,'No ❑Yes ❑No ',_]Unknown <br /> in.from to R. �;J Yes ❑No ❑Yes ❑No j_J Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner�s mailing address ii different than property owner's address indicated above SCfeen frOm_��_to �S1 r ft. OpBn Hole from tp ft. <br /> OBSTRUCTIONS � <br /> �tods/Drop Pipe [;Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)_ ,i�II�,V�It /'�� } / (//�� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions remaved? es <br /> FORMATION ❑NO DBSCfibB <br /> If not kn wn,indicate estimated formation log from nearby well or boring. PUMP <br /> .. r �,- TYPe Sv� � u m p . <br /> �emoved _Not resen[ ❑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. ❑Perforated []Removed € <br /> = Type of Perforator <br /> L <br /> L���f10f <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag ot bentonite=50 Ibs.) <br /> /�� r�G r <br /> Grouting Material.�I�r/ ��,r`�r�J�from �' to_S_� R. yards� bags <br /> from to ft. yards _ bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? [_I Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is hue to the best of my knowledge. <br /> Don Stc�dols_Well Dti12 Co.�Ir�. 1691 <br /> Licensee Business License or Registration No. <br /> - .� --'"" � ' � �I- �v�... <br /> Ce �e epresentativa; gnature Certified Rep.No. Date <br /> LOCAL COPY H <br /> 306210 � ,` ~ .--�"'��`..�� -- <br /> �N a�me ol Person Sealing Well Bonng <br /> HE-07434-12 IC#140-0423 4 siasR <br />