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MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring � ���0�t� � <br /> WELLOR BORING LOCAT�ON �yELL AND BORING SEALING RECORD sea���9 No. i H._ L <br /> counry Name Minnesota Uni que Well No. � -- � <br /> HENNEPIN M�nnesota Statutes.Chapter 1031 or W-series No. <br /> h.ew awc rc na tnown� <br /> Townshlp Name Township No. Range No Section No. Fracuon(sm.-►Ig.) Date Sealed Date Well or Bonng Constructed <br /> EXCELSIOR ��7 23 21 ��• SE� NW Wednesday,August 23,2000 <br /> Numerical Street Atldress or Rre Number and City oi Well w 0onng Loca6on 139 <br /> 2700 SHADYWOOD ROAD Deptn Beto�P sea���q _—n o�igina�oeptn _n <br /> Show exact locahon of N•ell or boring Sketch map ol well or bonog AOUIFER(S) STATIC WATER LEVEL <br /> in section grid wtlh"X'. location, showing properly �Single Aywfer ❑ MWtiaquRer <br /> lines,roads,and bwldinqs. <br /> N w �. WELUBORING �Measured ❑ Estimated <br /> § <br /> �Water Supply Well ❑Monit.Well �f <br /> I I - -- � � � Env.Bo�e Hole ❑Other _ GO R. �below ❑ above land surtace <br /> , , gar qe <br /> W '"�- - - -�-- - E CASING TYPE�S) <br /> ' v garane Black T8�C <br /> , � � � � <br /> —�- -;-- -i-- --�-- � ro �Steel ❑ Plastic �Tile �Other <br /> � � � � <br /> Yzmile ':`µ�/��'` CASING S <br /> __�_ _i__ _�__ __i__ � ( J <br /> shadtns�ood road Diameter Depth Set m oversrze hole? Annular space initially grouted? <br /> � S 3 0 139 ves (3jNo ❑ ❑ ❑ <br /> t mxe� in.from to ft. ❑ Yes No Unknown <br /> PROPERTV OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> NICOLLS,WILLIAM H. <br /> Properry owner's maihng address ii diHerem than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ UnknOwn <br /> 2700 SHADYWOOD ROAD SCREEWOPEN HOLE <br /> EXCELSIOR,MN 55331-9599 Screen+ror� �39 ro e open Ho�e trom to n. <br /> oesraucnoNs <br /> WELL OWNER'S NAME Rods/Dro Pi e <br /> � p p ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's meiling aAdreu if tlifierent than property owner's atltlress mtlicated above. Type of Obstructions(Describe) Removed 63�X�.Z�J��Drop Pipe 8 Jet Packer... <br /> Obstructions removed? [g Yes ❑ No Describe <br /> PUMP <br /> TYPQ Prior Removed Deep Well Jet Pump... <br /> 6EOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br />�- If rat krawn,indicete estimated formatbn log from nearby well or bonng. METMOD USED TO SEAL�ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE MOLE: <br /> iO.ivo Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Pertoreted ❑ Rertroved <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=501bs.) <br /> Neat Cmt p .3 0.00054 <br /> Grouting Material from to fl. yards bags <br /> Enviroplug .3 139 0.24966 <br /> from to ft. yards bags <br /> � <br /> irom to ft. yerds bags <br /> from to__ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER W ELLS AND BORINGS <br /> WEII LOC8t2fJ I!1 PU�YIP ROO�Y1 O�SOUtII SICIe Of B0S2R12(lY... Other unsealed and unused well or boring on property? ❑Yes �No How many? <br /> � LICENSED OR REGISTERED CONTRACTOR CEHTIFICATION <br /> Measured From Top Of Casing.... <br /> This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> Removed Cement&Drop Pipe From Well Prior To Sealing... Ma1211k@ W8t2f 763.493.3650 27600 <br /> Contractor Business Name �License a Registretion ivo. <br /> M ron Malenke � /:`�� , u ust 23, 2000 <br /> y :�'`��' ;l�.� {– �'`f�:�'�� <br /> 2� 117 23 24 0031 Authorized Representative Signature t Dare <br /> .�G�� ,"�J�y; u �/��O�/� Name ol Person Sealing Well a Bonng <br /> �, o L <br />