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WELL OR BORING LOCATION itINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 4 0 7 7 7 4 <br /> County Name — WELL AND BORINGSEALING RECORD Min nleso aoUnique Well No. <br /> HHENNEPIN Minnesota Statut , lhapter 1037 or W-series No. <br /> l--,.: (Leave dank M not known) <br /> Township Name Township No. Range No. Section No. Fr&ction(sm.—.lg.) Da ealed Date Well or Boring Constructed <br /> ORONO 117 23 17 IIWAIS SEk 2/28/2024 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Deoth at Time of Sealing 243 ft. Original Depth _ _ ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ]Single Aquifer ❑Multiaquifer 2/28/2024' <br /> WE Estimated <br /> 2232 SLIADYWOOD RD. ,WAYZATA,MN LL/BORING �Measured Date Measured <br /> 3�; �]Water-Supply Well ❑Env.Well 44 <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X." location,showing property ❑Temp.Boring ❑Other ft. A below ❑above land surface <br /> N lines,roads,and buildings. CP6INGTYPE(S) <br /> a. <br /> SEI Steel ❑Plastic ❑Tile ❑Other <br /> _----"" ` "' WELLHEAD COMPLETION <br /> W ET <br /> • Outside: k]Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> - - 1mile ❑Well Pit ❑Buried ❑Well House <br /> ---•------- ❑Well Pit ' <br /> r s y-1 ❑Other <br /> ❑Buried <br /> I I Mile 1k Othe <br /> ❑Other <br /> For temporary borings,provide additional location CASING(S) <br /> information,a site sketch,and.eology on a separate)' Diameter Depth 3 5 Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from1 to ft. ❑Yes ❑No ❑Yes ❑No in Unknown <br /> SCkiERBER CO <br /> Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 4! <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEWOPEN HOLE <br /> Screen from235 to 243 ft. Open Hole from to ft. <br /> L O ER'S NAME/COMPANY NAME <br /> C E MjDDEN'DORF OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above C]Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> DROP` PIPE <br /> Type of Obstructions(Describe) <br /> Obstructions removed? I Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Notc+Pr�etsent D®+*Present�pRemoved Prior to Sealing ['Other <br /> If not <br /> known,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE <br /> DRIFT I r T 1 243 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> 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 /> GroutingMaterial NEAT CEMENT„, 1 to 243 ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes I 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 <br /> is true to the best of my knowledge. <br /> DON STODOLA WELL DRILLING CO,,INC. 1691 <br /> Licensee Business N e License or Registration No. <br /> 558 2/28/2024 <br /> rtiif Representah''e S�rur Certified Rep.No. Date <br />�� 9 P <br /> LOCAL COPY H 4 0 7 7 7 4 JERRY BARR <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 wise <br /> /t gR <br />