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I <br /> WELL OR BOFING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Bogt�p. ,� n n O�� <br /> WELL AND BORING SEALING RECORD Sealing No �,� � i� <br /> ..;.,r <br /> County Name Minnesota Unique No ��-- <br /> Hennepin Minnesota Statutes.Cha ter 1031 0� <br /> p or W-series No. <br /> (Leave blank A noi known) <br /> Township Name Township No. Range No. Section Na Fraction�sm.-�Ig.) Date Sealed Date Well or Boring Con ructed =,G�'� <br /> rono 117 23 11 , � I �.,�CT 7 _��.� UF�O,• <br /> Numerical Sireet Address or Fire Number and Ciry of Well or Boring Location / / <br /> �4 C Q Shorel ine Dr. �Z'U2I0� MIl.5 5� ��h Before Sealing f�%�/ ft Original Depth /���j n. <br /> Show exact location of v,�ell or boring Sketch map�of�weil�or'boryig A UIFER�S) STATIC WATER LEVEL <br /> in sec�ion grid with"X". location,�showing propetty Single Ayuifer � Multiaquifer <br /> lines,ro�ds.and building�. <br /> N .. . � WELUBORING Measured ❑ Estimated <br /> � � � � <br /> i �� �- WaterSupply Well ❑Monit.Well � <br /> -- - -r- --,-- --i-- � _' � — '.. <br /> � r *,( <br /> I 1 7 ❑ Env.Bore Hole ❑Other �a�� N. ,Cy,,below ❑ above land surface <br /> � � <br /> � � --i-- <br /> —r '�-- -r- <br /> W E CASING TYPE(S) <br /> � � � � <br /> � � � <br /> I I � _..__ <br /> --�- -�-- --�-- --'�-- �, .`` Steel ❑ Plastic ❑Tile �Other <br /> '4 m�le <br /> y;. <br /> --�- -'�-- --�— � ( CASiNG <br /> Diameter� Depih , Set in oversize hole7 Annualar space initially grouted? <br /> � � � � � � <br /> �i r��ie� _ : r.�� J in.from� to/�`"� fl. ❑ Yes �No ❑ Yes ❑ No ❑ Unknown <br /> . ..�. . � �-. <br /> PROPERTY OWNER'S NAME in.from to tt. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> 7 <br /> Property owner's mailing address if diHerent than well locauon ad ress indicated above. in.from [o ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> ;;��4 Florida Ave. SCREEWOPEN HOIE � , <br /> C�YStc�1� �.J��L l Screen from / ��^'� to r �� ft. Open Hole f�om to ft. <br /> ���-���� oesrRucnoNs <br /> WELL OWNER'S NAME Rod Dro Pi <br /> �p p� ❑Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction <br /> Well owner's mailing address if diflerent than property owner's address indicated above. Type of ObSlfuCtiOnS(D6SCfibB) <br /> Obsiructions removed?�f Yes ❑ No Describe ± ��`' �''� fi -� � �- � �`� L�+�� <br /> PUMP <br /> TyPe .�,�.��' {����..'�)I,'�: <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> fORMATION <br /> If not krwwn,indicate estimated formation log trom nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> " No Annular Space Exits <br /> .�r� <::� �y <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforetion/Removal '� <br /> in.trom_ to ft. ❑ Perforated ❑ Removed <br /> in.from to tt. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> /�'�/�', ;'�J;�lf-;t!' �� ��� / �< <br /> Grouting Matenal �� - from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to__ fl. yards bags <br /> REMARKS,SOURCE OF DATA,OIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes �No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation contained in this repoA is <br /> true to the best ot my knowledge. <br /> UC>N STC�DOLA WELL DRILLING CG. , INC. �ii"12 <br /> Contractor Business Name /' _ , License or Registration Pvo. <br /> , <br /> / <br /> �/�'_..,,'� _s / , . . ._�...f �. .�'` <br /> �-"'" ! <br /> Authonzed Representative Signature Date <br /> �"l,,.r,e„.,, <br /> LOCALCOPY H <br /> 12 9 019 Name o/Person Sealing Well or Boring <br /> HE-01434-03 2/97 R <br />