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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring l <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> HENNEPIN p Leave blank down) <br /> Township me Township No. Range No. Section No. Fraction ism->Ig) Date Sealed Date Well or Boring Constructed <br /> /aLoo C) 117 23 07 Ver' 5C Friday,December 19,2003 <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing 220 ft. Original Depth CWi-III record ft. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL Fill <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ElMultiaquifer CFND <br /> 1345 VINE PLACE WELUBORING [Measured El Estimated <br /> [X Water Supply Well ❑MOnlf.Well <br /> Show exact location of well or boring Sketch map of well or boring / ��n� / <br /> in section grid with"X" location,showing property [:]Env.Bore Hole E]Other 50 ft. below above land s?12 0S <br /> N lines,roads,and buildings. CASING TYPES) _ <br /> 4'x 220'weft 0110)VO <br /> E]Steel Plastic E]Tile E]Other Plastic <br /> -�- -;-- -;-- --;-- f?--�'- WELLHEAD COMPLETION <br /> W E <br /> �{ — Outside: ❑Well House Inside: ❑Basement Offset <br /> j4mie glraye > �_Pitless Adapter/Unit ❑Well Pit <br /> m ❑Well Pit ❑Buried <br /> S <br /> --1.0. " ! ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> DAVIS.MARGARET M. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address it different than well location address indicated above <br /> 4_ in.from 0 t0 215 ft. ❑Yes ❑No E]Yes ❑No E]Unknown <br /> 1345 VINE PLACE <br /> " in.from to ft. ❑Yes ❑No E]Yes ❑No E]Unknown <br /> MOUND,MN 55364 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above Screen from 215 to 226 ft. Open Hole from t0 ft. <br /> SAME OBSTRUCTIONS <br /> LX Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) Removed 75'X 1.00"Poly Drop Pipe And Submersible Pump... <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM FORMATION TO Obstructions removed? Yes ❑ No Describe <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Clay Type Sibinerisle Prunp <br /> Removed ❑ Not Present ❑Other <br /> Sand(Fine) 65 170 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> Clay 170 205 EX No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> Sand 205 <br /> 216 in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Drilled-1984 <br /> Depth-4"X 216 Type of perforator <br /> Screen-212-216' ❑ Other <br /> Static Water- <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material Neat Cement from—_5 to—5..5—ft._0.001-6 yards bags <br /> Enviroplug from 5 Al to 220 - , 0 6864 yards bags <br /> from to yards bags <br /> GEOLOGY FROM: 4 NORTH$ E DR OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes No Ho any? <br /> w comer of house LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> pitless adapter located 20'nw <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.;-he information contained in this report is <br /> well depth measured from grade level true to the best of my knowledge. i <br /> mdh staff was not on site during well sealing Myr L 111111aierdue!Lialimillim Water (763)493.3650. 27600 <br /> Contractor Business Name / ense or Registration No, <br /> verification of notification was received from mdh <br /> j. <br /> M.L.MalerAce <br /> D eoerriber 19,2003 <br /> 07 117 23 42 0004 Authorized Representative Signature ate <br /> LOCAL COPY H 216339 Name of Person Sealing Well or Boring <br />