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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring � 13971 Q� . <br /> WELL AND BORING SEALING RECORD Sea�ing No H <br /> County Name Minnesota Unique No. -- —1 <br /> Hennepin Minnesota Statutes,Chaprer�03� or W-series Na �__ � <br /> ILeave blank if not known� <br /> Township Name Township No. Range No. Seclion No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Gonstructed <br /> arono lI7 23 08 3 ,�!0017 �.. <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring�ocation <br /> 1470 Cherrp Place, �r�n� Depth Before Sealing 2�__ fl Original Depth �l�h <br /> Show ezact location of well or boring Sketch map o(well r�ooring ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing�roperty Single Aqwfer ❑ Multiaquifer <br /> lines,roads,and bGildings. <br /> N 1 WEWBORING Measured ❑ Estimated <br /> .,_.._ Water Supply Well ❑Monit.Well / <br /> - - - - - -- --;— j� _+ � /� <br /> { ` ❑ Env.Bore Hole ❑Other _ _..�C�/_R. �below ❑ above land surface <br /> � � � � , <br /> � � � � �, � <br /> W --r- -�-- -�-- --�— E � �� � CASING TYPE(S) <br /> � � � ; <br /> i i i � <br /> i i i 1� `, ' <br /> -�-- -�— --;-- --�-- �1`` ���, Steel ❑ Plastic ❑Tile ❑Other <br /> u mde � <br /> --`- -�-- —�-- --1-- �.,. � CASING <br /> �;, Diameter t� Depih / Set in oversize hole? Annualar space initially grouted? <br /> S """��J""" . ...,_._...,_..... j <br /> �t miie—�s � in.from� to� R. ❑ Yes �No ❑ Yes ❑ No ❑ Unknown <br /> I <br /> PROPERTV OWNER'S NAME in.from to tt. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Ra G e - <br /> Pioperty owner's mailing address if different ihan well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> i ^�/�/ ' <br /> Scieen rrom�_toGi.� ft. Open Hole from ro fl. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Dro Pi e ❑Check Valve s ❑ Debris <br /> � p p O ❑ Fill No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type ot ObstruCtions(DesCribe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> TYPe�/i�.[JI� /'"!) �— <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or ponng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � No Annular Space Ezits <br /> ❑ Annular space grouted with tremie pipe <br /> J��� ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> F <br /> in.from to fl. ❑ PeAorated ❑ Removed <br /> Type of perforetor <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> � /j 1 <br /> Grouting Materi��� �j ��f i/�-�, from S._,� to,�}__ ft. yards �— bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> irom to__ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATIO <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. <br /> Don Stodols Well Drilling Co., INc. 27172 <br /> Contracror Business Name � �.- License or Registration ivo. <br /> ;' J , f - <br /> � ,�" � j' _ ��r <br /> � <br /> f <br /> t z qepresentative Signature Dafe <br /> � <br /> :f�— <br /> p.s:i-�. .�.� <br /> LOCALCOPY H <br /> 13 9 714 Name ol Person Sealing Well or Bonng <br /> HE-01434-03 2/97 R <br />