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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well Boring 4 O 7730 <br /> WELL OR BORING LOCATION Sealing No. H <br /> W <br /> ELL AND BORING SEALING RECORD •County Name Minnesota Unique Well No. <br /> 4; lEN EPIN Minnesota Statutes,chapter 1031 or W-series No. <br /> (Leave dank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-lg.) Date Sealed Date Well or Boring Constructed <br /> ©RONO . 117 23 10 SE'SE W ', 1/11/2024 <br /> GPS LOCATION-decimal degrees(to four decimal places) 173 <br /> Depth at Time of Sealing ft. Original Depth ft. .. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location fe Single Aquifer ❑Multiaquifer <br /> 1245 LAKEVIEW AVE. :WAYZATA.4N WELL/BORING X Measured Date Measured 1/11/2094 Estimated <br /> ®Water-Supply Well ❑Env.Well 52 <br /> Show exact location of well or boring ,,.553 Sketch map of well or boring <br /> in section grid with"X." ocation,showing property ❑Temp.Boring ❑Other ft. below ❑above land surface <br /> N r • lines,roads,and buildings. CASING TYPE(S) <br /> a <br /> C VftAVE:4 VE, [.Steel ❑Plastic ❑Tile ❑Other <br /> WELLHEAD COMPLETION <br /> w E{ . <br /> TOutside: C Pitless Adapter/Unit El At Grade Inside: ❑Basement Offset <br /> { I Mile Well Pit ❑Buried ❑Well House <br /> �---t --T-- 1.- 1 <br /> S I Well Pit <br /> `- ❑Other ❑❑Buried :..r <br /> 1- 1 Mile { <br /> A ❑Other <br /> For temporary borings,provide additional location • CASING(S), <br /> information,a site sketch,and geology on a separate page. Diameter/ • Depth Set in oversize hole?. Annular space initially grouted? <br /> PRJP. A kil RR'SSNAM�tE OMP NY NAME 4 in.from I to 165 ft. ❑Yes ❑No ❑Yes ❑No g Unknown <br /> Property jjojjwner's mailing address if different than well location address indicated above in.from' to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> (" ' .in.from - to • ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 1 SCREEN/OPEN HOLE, <br /> I Screen from 1 V 5 to 173. ft. Open Hole from to ft. <br /> WELL OWNER'S NAME/COMPANY NAME <br /> J --•- -- - <br /> f ENNIFER NORD OBSTRUCTIONS .- gr ,.- v + k' .ti. , . <br /> Well owner's mailing address if different than property owner's address indicated above I Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> ' DROP PIPE <br />) Type of Obstructions(Describe) <br /> l <br /> Obstructions removed? 1 Yes ❑No Describe <br /> PUMP <br />( GEOLOGICAL MATERIAL_ COLOR HFORMATI oR FROM TOORMATION ❑Not Presentreseennt ®Present,Reemooved Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE <br /> DRIFT 1. 173 <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE - <br /> ZJ No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal. <br /> - Casing Diameter <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE ^ <br /> Was a variance granted from the MDH for this well? ❑Yes ®No TN# - <br /> GROUTING MATERIAL(S) ' <br /> NEAT CEMENT 1 173 14 - <br /> Grouting Material from to ft. yards bags <br /> 'ti <br /> from to ft. yards bags <br /> l,. from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes ®No How many? - <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING, - . This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report i <br /> is true to the best of my knowledge. - 1 <br /> I. ,t, - ,1 - i <br /> : ? .- DON �r.�ryy'� x WELL <br /> 1. <br /> t- _ .: a31ODOLA` TN Li'L.ia CDRILLING .r . INC. 1691 - - i:. <br /> Licensee Business Name ' License or Registration No. <br /> f - 558 1/11/2024 <br /> i; . C ifpd'Representative Signature Certified Rep.No. Date <br /> W' <br /> r} <br /> LOCAL COPY H 4 07730 <br /> .Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 - 11/19R <br />