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wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 0 5 6 91 <br /> County Name <br /> WELL AND BORING SEALING RECORD MennlesoNa Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> I3�►nne in ��ea�eb�a�k,,�o�k�ow�, <br /> Township Name Township No. Range No. Section No. Fraction(sm-►Ig) Date Sealed Date Wetl or Boring Constructed <br /> �rono 118 23 27 3�0425 ' / 4%�, 1 � � <br /> , , <br /> GPS Latitude degrees minutes seconds �,�� ft. <br /> LOCATION: Depth Before Sealing /�� fL Original Depth <br /> Longitude degrees minutes seconds qpU1FER(S) � STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> W1,�LL/BORING �Measured ❑Estimated <br /> � IY Water Supply Weli ❑MoniL Weil � <br /> Show exact location of well or boring Sketch map of well or boring �� '!�� <br /> in section grid with"X" location,showing property ❑ Env.Bore Hole ❑Other � ft. �below ❑above land surface <br /> lines,roads,and buildings. <br /> N � CASING TYPE(S) <br /> - - - - -- -- -- — � <br /> r ,� I�Steel ❑Plastic ❑Tile ❑Other <br /> 9, T� <br /> W —�- - -- - -- -- -- E �) �-9� WELLHEAD COMPLETION <br /> t <br /> , � � � � l Outside: ❑Well House Inside: ❑Basement Offset � <br /> -�-- -�— ' �— .. <br /> � <br /> Y�mi�e �� �itessAdapter/Unit ❑Well Pit ��� <br /> -r- -i-- -�-- --�— _, • :.' <br /> } .... ❑Well Pit ❑Buried <br /> S <br /> �r mde� <br /> ❑ Buried <br /> PROPERTY OWNER'S NAME/CTOMPANY NAME CASING(S) <br /> S .i� Diam eff Depth � Set in oversize hole? Annular space initiall;�grouted? � <br /> Property owner's mailing address if different than well location address indicated above . <br /> in.ffOm� to�ft. ❑Yes �o ❑Yes ❑No ❑Unknown <br /> I8340 l�iinnetonka Blvd <br /> W�yzata, MN 55391 in.from to ft. ❑Yes ❑No ❑Ye5 ❑Na ❑Unknown <br /> in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> /� / / <br /> Well owner's mailing address if different than property owner's address indicated above Screen from F-��t0���ft. Open Hole ffOtll t0 ft. <br /> OBSTRUCTIONS <br /> C�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill O No Obstr/uc�tion <br /> Type of Obstructions(Describe) ...LN/V�� �-�/'L �' / U�/!� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO ObSt�UCtiOnS�emOved? 2S ❑ NO Describe <br /> FORMATION <br /> It not known,indicate estimated formation log from nearby well or boring PUMP (} n <br /> ` TYPe '`'f' U� i V M i , <br /> ��. J - ` <br /> �Removed ❑ Not Present ❑Other ; <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> y�vo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> /� <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> A' / �{�� r <br /> GroutingMaterial F�`�����`���dm � 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 unseaied and unused well or boring on property? ❑ Yes 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 is <br /> true to the best of my knowledge. s� <br /> Don Stadnl a �dPt l <br /> � Contractor Busin s Name . ... License or Registration No. ¢ <br /> , - <br /> � ,. " � �- � �� <br /> t iz ep�entative Sigrtatur2 Date <br /> LOCAL COPY H 'n��Q 1 <br /> � ��3��/�^-'�\R���^' <br /> Name ol Person Sealing I or Boring <br />