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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 266470 <br /> WELL Na BORING LOCATION WELL AND BORING SEALING RECORD Menne o a Unique well No. " <br /> County Name <br /> iR Minnesota Statutes,Chapter 1031 or W-series NoHermp . <br /> (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm. Ig.) Date Sealed Date Well or Boring Constructed <br /> orono 117 23 08 2-110M '� t--,c7 Q <br /> GPS Latitude degrees minutes seconds Depth Before Sealing ,y� ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes_ seconds IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer F]Multiaquifer <br /> 1220 iodkmm Rd. Omm W LUBORING Measured ❑Estimated Date MeasuredsOOX- 6A K <br /> Water-Supply Well ❑Monit.Well f <br /> Show exact location of well or boring map of well or boring <br /> in section grid with"X" locat n,showing property ❑Env.Bore Hole ❑Other ft. �]below ❑above land surface <br /> lines roads,and buildings. <br /> N CASING TYPE(S) <br /> Steel [-]Plastic F]Tile ❑Other <br /> d s <br /> ----'-'--'-- -----`-- WELLHEAD COMPLETION <br /> W ET <br /> ------, <br /> ____ _____ II Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> 'h Mile ltless Adapter/Unit ❑Buried ❑Well Pit <br /> �P' <br /> ---- <br /> ❑Well Pit ❑Buried <br /> s ❑Other <br /> 1 Mile N <br /> ❑Other <br /> PROPERTY OWNER'S NAMMEE//COMPANY NAME CASING(S) <br /> Steiner al Ko 1mw Inc Di"am�eter f Depth f Set in oversize hole? Annular space initially grouted? <br /> Prop�rot•340 m r�( ni.tha tion address indicated above �/1,in.from to ft. Yes No Yes ❑No ❑Unknown <br /> Wayzata, MAT 550391 —t <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLL��E�� r / <br /> Well owners mailing address if different than property owner's address indicated above Screen from q a to /0/ ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check/Valve(s) ❑Debris ❑Fill ❑No/O/b/s�truction <br /> Type of Obstructions(Describe) ToyA tex �P05 g ! (JM19 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es E]No Describe <br /> FORMATION <br /> PUMP <br /> If not nown,indicate estimated formation log from nearby well or boring. �j- Type <br /> Removed ❑Not Prelent ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> )Jo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe L]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 /> .�. i 41 <br /> Uy� <br /> Grouting Materia4%•&�&/fr.om_40 tom 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 Xo 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 <br /> is true to the best of my knowledge. <br /> don Stole Well Drilling CA., Im. 16% <br /> Licensee Business Name License or Registration No. <br /> epresentative Signat&M Certified Rep.No. Date <br /> LOCAL COPYH ` <br /> 26`+S���+''/�I Name of Person Sealing Well or Boring <br /> HE-01434-10 IC#140-0423 5/07R <br />