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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL DR BORING LOCATION WELL AND BORING SEALING Sealing No. �H <br /> RECORD <br /> 161881 <br /> County Name Minnesota Unique Well No. r --- <br /> Hennepin Minnesota Statutes.Chapter 1031 or W-series No. <br /> (Leave desk n ria k-1) L <br /> Township Name Township NTRan;ge No. Section No. Fraction(sm.i Ig.) Date Sealed Date Well or Boring Constructed <br /> Orow IIF 27 31 Q <br /> Numerical Street Address or Fire Number and City of Well or Boring Location r <br /> TOrono Depth Before Seating _-_ft Original Depth h <br /> 3760oo Rd <br /> Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X' Ioc Y Single Aquifer ElMuluaquder <br /> roads.and burden s <br /> N .3u.* W�LL/BORING <br /> Measured El Estimated <br /> f/. r �EJf Water Supply Well ElMonit Well <br /> °(} 20 or <br /> E] Env Bore Hole ❑Other — ry below ❑ above land surface <br /> W ---- - -- - -- --'-- E CASING TYPE(S) <br /> - - - -- -;-- --i-- Steel ❑ Plastic ❑Tile ❑ Other <br /> }smile <br /> -- CASING(S) <br /> Dianer Depth mac,41 to <br /> in oversize hole? Annular space initially grouted? <br /> 01 <br /> f mile s �4' A in.from �✓ to- ft. ❑ Yes No ❑ Yes ❑No ❑ Unknown <br /> 2PT <br /> PROPERTY OWNER'S NAME in,from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> r <br /> Property owner s maihng address if different than well location address indicated abovein,from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> it <br /> /1 2 SCREEN/OPEN HOLE <br /> 1f tf <br /> Screen from 3 U to �L ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME ❑ Rods/Dro Pipe Check Valve(s <br /> ) E] Debris E] Fill WNo Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above Type of Obstructions(Describe) <br /> Obstructions removed? ❑ Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL I COLOR HARDNESS OF FROM TO ❑ Removed A Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> )6o Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ry. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 lbs.) <br /> _ r.1 SMG � �1 <br /> Grouting Material N4,4,T(,�,� A-llfrom �..�/ to_sL I ft. yards bags <br /> from to _ ft. yards bags <br /> . -. from to... ._ _ ry.-, yards bags <br /> from to— fL yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑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 is <br /> true to the best of my knowledge. <br /> Dan St©dols WEli Drilling Co., Inc. 27272 <br /> Contractor Business Name - L"nse or Registration rvo. <br /> > I1-1,9'9 <br /> [�Auhg�i6�'nzed Representative Signature Date <br /> Jtm Antonson <br /> i_OCAL COP,6H {�Q 161©81 Name o/Person Sealing Well or Boring <br />