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i <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I <br /> County Name <br /> WELL AND BORING SEALING RECORD Menn'esoNa Unique Well No. <br /> Minnesota Statutes,Cha ter 103! or W-series No. <br /> P �Leave�lank i�not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed - <br /> �.:� - ,,�(� � y <br /> GPS Latitude._ degrees __ minutes seconds Depth Before Sealing `� � ft. Original Depth ft. <br /> LOCATION: Longitude__ degrees__ minutes seconds <br /> --"��-"-- A�UIFER(S) STATIC WATER LEVEL <br /> Nume�r}ic'al/S�treet Ayddress or Fire NJumber and City of Well or Boring Location ' Single Aquifer j-JI Multiaquifer . `� ,�:.f <br /> j f Gil �OL1(j$ �1n� Rd� ��'(x� WELUBORING Measured ❑Estimated Date Measured `�' 1 <br /> �Water-Supply Well ❑Monit.Well � <br /> Show exact location of well or boring etch map of well or boring - <br /> in section grid with"X." � cation,showing property �..j Env.Bore Hole ❑Other `"��� ft. ❑below ❑above land surface <br /> N �h lines,roads,and buildings. CASING TYPE(S) <br /> --'--- --'--- ---`-----'-- � <br /> ,!����1� �Steel ❑Plastic [_.]Tile ❑Other �'' <br /> --'-----'--- ---�-----�-- WELLHEAD COMPLETION <br /> W � ; � : ET <br /> __;_____;_____�_____r._ Outside: ❑Well House ❑At Grade Inside: �Basement Offset <br /> � � � � , Mile i� ❑Buried ❑Well Pit <br /> �� ' ' ' � �� �'� o �� ❑P'less AdaptedUnit <br /> --:---r-----.----:-- 1 ,.,,�, 3 ' <br /> ❑Well Pit ❑Buried <br /> S ❑Other <br /> F--1 Mile� U Other____ <br /> PR ERTY WNER' N MPANY NAME CASING(S) <br /> �ar�� �ti`�i�ers <br /> � Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Properry owner's mailing address if different than well location address indicated above � / lj�-/ <br /> � in.from ..C% to tt. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> Zb04 66th St W <br /> Richfield, I�1 55423 in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> ,_� �r� � in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE/ <br /> Screen from C` �" to C• � ft. Open Hole from to ft. <br /> Well owner's mailing atldress if diflerent than property owner's address indicatetl above � <br /> OBSTRUCTIONS <br /> � ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> If not kpown,indicate estimated formation log from nearby well or boring. PUMP <br /> • O t Type <br /> f"" ❑Removed �Not Present ��Other ____ <br /> 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 /> 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 Ibs.,one bag of bentonite=50 Ibs.) <br /> ,/� i' � �_/l" I <br /> Grouting Material/� `�--�'� '-�'� 4ro� � to �'� 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? ��I,Yes I o 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 /> . . Dan Stodola We31 Drilling Co,. Icic. 1691 <br /> �i Licensee Business Name � � License or Registration No. <br /> �,_ <br /> � �.. ��. � ���� �'7 <br /> i _ - /./ �' - ...j ;� ! ` J ! <br /> Certified Repres ative Signature Certilied Rep.No. Date <br /> H Z�W Z�Z � -r 7'`..r �T ��!'�iCl-+S�('�'�' <br /> ��'i L`'JFY Name ol Person Sealing Well or Boring � <br /> HE-01434-11 IC#140-0423 � voea <br />