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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring /�/� �� <br /> County Name - WELL AND BORING SEALING RECORD MinnSealesota <br /> to H LJ 4J <br /> Minnesota Unique No. <br /> HENNEP 1 N Minnesota Statutes,Chapter 1031 or W-series No. 2 <br /> 966 <br /> (Leave blank if not known) <br /> ak6one Township No, Range No. Section No. Fraction ism.-,,Ig.) Date Sealed Date Well or Boring Constructed <br /> 119 23 8 E XW ME, NOV 03, 1997 09-28--96 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 980 TONKAWA RD Depth Before Sealing 135 ft Original Depth ? ft <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- location, showing propertySingle Aquifer ElMultiaquifer <br /> lines,roads,and buildings. <br /> N WELUBORING Measured ❑ Estimated <br /> I Water Supply Well ❑Mont.Well <br /> - <br /> I Nt e,4� ❑ Env Bore Hole ❑Other 60 ft. below Elabove land surface <br /> W --r•-----------------------E - CASING TYPE(S) <br /> - -- - -- -i-- -- Steel ❑ Plastic ❑Tile ❑Other <br /> —le <br /> 1 <br /> r. t <br /> CASING <br /> 1 Pi{ S yy Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> LlS """�J�""" Y 4 0 130 fvl Yes No Unknown <br /> 1 mile `"' in.from to ft. ❑ Yes `fes No ❑ ❑ ❑ <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> TOM POTTER CONSTRUCTION INC; <br /> Property owner's mailing address if different than well location address indicated abovein,from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> 165-31 DEVONSHIRE DR SCREEN/OPEN HOLE <br /> HMHAS SEN, MN 55317 Screen tram 130 to 135 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill 14 No Obstruction <br /> SAME <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 �}fi <br /> RE Cali <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ,6 Removed ❑ Not Present [I Other <br /> FORMATION <br /> It not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CAS�uuMDQO <br /> 'LAY YELL Q 2C) dr FWV-1 <br /> r No Annular Space Exits YY LL q�' <br /> ED Annular space grouted with tremie pipe �^ v�:URONO <br /> SAND GRAY ARG 60 ❑ Casing Perforation/Removal vlY <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> BENTONITE 135 SURF '• <br /> Grouting Material from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to_ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> GEOLOGY FROM: UNIQUE #562966 Other unsealed and unused well or boring on property? ❑Yes P!rNo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> WATER LEVET. IN ABOVE WELL: 60 <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> DATE WATER LEVEL TA KEN: 09-28-96 true to the best of my knowledge. <br /> "-157 <br /> E.H. RENNER & SONS, INC, 7.1015 <br /> Contractor Business Name License or Registration No. <br /> 11/5/97 <br /> �r `r Authorized Re sentative Signature Date <br /> -,cording to MN Ctate Rcr►olatir Ii� KEVIN SCHEITERLEIN/RAY RENNER <br /> LOCAL COPY 7H <br /> 129771 Name of Person Sealing Well or Boring <br /> HE-01434-03 2/97 R <br />