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WELL oR BORING LOCanON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' f�A� <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesotaoUnique Well No. `3 <br /> Hennspin Minnesota Statutes,Chapter 1031 1�W����� <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Construc[ed <br /> Orano 11?N 23kt 10 ,. .,. S� =:—L�}--C ;.r <br /> GPS Latitude degrees minutes seco�ds , �. <br /> LOCATION: Depth Before Sealing V '� ft. Onginal Depth �``�� ft. <br /> Longitude degrees minutes seconds ppUIPER(S) STATiC WATER LEVEL i� <br /> Numerical Sheet Address or Fire Number and Ciry of Well or Boring Location Single Aqui(er ❑MultiaquNer - - <br /> 1860 Shoreline Dr, Wayzatn WELUBORING �Measured ❑e��rea <br /> �Water Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map ot well or bonng .::k ;-. <br /> in section gnd with"X" location,showing property ❑Env.Bore Hole ❑Other f�^ ft. bebw ❑above land surface <br /> N � lines,roads,and buildings. CASING TYPE(S) <br /> �% <br /> - - - - - -- - - �1 .u..''� <br /> I � � <br /> �„Steel ❑Plastic ❑Tile ❑Other <br /> W --� -- - -- --i-- E � WELLHEAD COMPLETION <br /> � � � � � � - Outside: ❑Well House Inside: ❑Basement Offset <br /> � <br /> --r- --r- -�-- -- -- . . <br /> �^�'b � ❑Pitless Adapter/Unit ❑Well Pit - <br /> -;- -i-- -i-- --i-- I <br /> 1 � �Well Pit ❑Buried <br /> ' S . _ '�. .._. .._..._._.._.�..__.. <br /> :. �r rrwl�� . � -� .—.r..•—,�``,-=a—....- <br /> ..'.._'..." ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Trc��� �YDlt2'1l1cdT1 Diameter Depth Setinoversizehole? Mnularspaceinitlallygrouted? <br /> Property owner's mailing address if diHerent than well location address indirated above ,� �. <br /> in.ffOm �--' to '"—' ft. ❑Yes f�7 No ❑Yes ❑No �Unknown <br /> t8�i0 Shc►reline Bz •r� <br /> Tdapaata, Mtd 55391 in.from to n. ❑res ❑No ❑ves ❑n,o ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑ves ❑No ❑uMcnown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> T�'O" BtOit2laan <br /> - Well owner's mailing address if differeM than property owner s address indicated above Screen from ����' to '"'`� ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> �( Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ,Yes ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or bonng PUMP <br /> Type _ :�-, �:� <br /> �Removed ❑ Not Present ❑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 Perforadon/Removal <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=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> ��� <br /> ; i:a_� <br /> Grouting Material � from to (t. yards � bags <br /> from to ft. yards bags <br /> from ro ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING pther 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 report is <br /> true to the best of my knowledge. <br /> S�e�se��: ')rzl.li.ng �4 Er��srirc�ixn�r,��l Svc 8665� <br /> Contractor Business Name License or Registrafion No. <br /> �/��,'�` �(.�, . <br /> - .. . - r ��. r <br /> Authonzed Representative Signature Date <br /> LOCAL COPY <br /> H �35246 � :�,�-�.�� r� �_, ,.; , � ��.,��.) <br /> Name of Person Seal�ng Well or Bo <br />