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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 249106 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> HennepinMinnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave meek if rat k—) <br /> Township Name Township No. Range No. Section No. Fraction Ism i Ig) Date Sealed Date Well or Boring Constructed <br /> Oroeo 117 3 OP 21 2 f <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing ft. Original Depth ft. <br /> Longitude degrees minutes secondsO FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> I .Te t� WELL/BORING Measured ❑Estimated <br /> X325 �• w'a A OroI 7 <br /> Show exact location of well or boring Sketch map of well or poring (Nater Supply Well E]Monit.Well <br /> in section grid with'X" location,showing pro rty ❑ Env.Bore Hole ❑Other ft. [ frelow E]above land surface <br /> N lines,roads,and buil ngs. CASING TYPE(S) <br /> T Y teel ❑Plastic ❑Tile ❑Other <br /> W -�- - -- - -- --�-- E WELLHEAD COMPLETION <br /> Outside: ❑Well House Inside: ❑Basement Offset <br /> Xitless Adapter/Unit E]Well Pit <br /> -�-- -i-- -�-- --i-- � t` TTTTTT```"` <br /> ❑Well Pit ❑Buried <br /> S <br /> \\ <br /> ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter r Depth t Set in oversize hole? Annular space initially grouted? <br /> Prole i ad a t o do ess indicated above r <br /> ��,y � in.from� to�ft. E]Yes f�Mo E]Yes ❑No E]Unknown <br /> 7407 wagzat'a Blvd ❑Yes ]]No Yes No <br /> in.from to ft. ❑ ❑ ❑ E]Unknown <br /> Mirmeaolis, T1 55426 <br /> in.from t0 ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> r <br /> Well owner's mailing address if different than property owner's address indicated above Screen from if 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 /> -J41 o0q 49 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Xes ❑ No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Type ^ <br /> Removed ❑ Not Pres nt E]Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ly No Annular Space Exists El Annular space grouted with tremie pipe El Casing Perforation/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 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material/0.-�''�/�l�rh'r/�Zfrom�' to "n ft. 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? ❑ Yes XNo 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 /> Don Stodola Well Drillim, Co,. Inc. 2ilW 16" <br /> Contractor Bus' sS-Name License or Registration No. <br /> AtffhorlYed Representative Signature Date <br /> H 2491.0E ->�- <br /> LOCAL COPY <br /> Name of Person Sealing Well or Boring <br />