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7 ". WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ir ��A —� Counry Name WELL AND BORING SEALING RECORD sea''�9"°. i H_ � Minnesota Unique Well No. ��x��.� Mmnesota Stafutes.Chapter 1031 or W-series Na �_ � hmrs da�x rc�a x�� Township Name Township No. Range No. Section No. Fraction�sm.-i Ig� Date Sealed Date Weli or Bonng Constructed � 1�# 2� ft S 1+��: ��:`' l�Lli� «3C?, �t:3{3{� 19�J{3" w Numencal Street Address or Fire Number and Ciry of Well or Bonng Local�on . �� ^ �.�� R��# Depth Before Sealing ��¢�� tt. Original Depth __h Show exact location of N-ell oi bonng Sketch map ol weli or boring ApUIFEF(S) STATIC WATER LEVEL m secfion grid wrth"X'. location, show�ng property �Single Aywter � Multiaquifer tt'; lines,roads,and build�ngs. N t� WELUBORING �'Measu�ed ❑ Eshmated � � � � R Water Supply Well ❑MoniL Well I �� ❑ Ern.Bore Hole ❑Other ��} R �below ❑ above land surtace W - -- - -- --,-- E X�! � l�,` CASING TYPE�S) --f- I i �u i I � �Steel ❑ Plastic �Tde � Other -�-- � ---' -�— - }�1 mile --�- -�-- -�-- --1— � ��t CASING(S) '�� Diameter Depth Set�n oversize hole? Annular space initially grouted? �l� S �mi�e� ! � in.from� to�� ft. ❑ Yes �No ❑ Yes ❑No ❑ Unknown PROPERTV OWNER'S NAME �� in.trom to k. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown ' NWYN = _, roperty owner's mai ing a ress� i erent than well location address indlcared above. in.from to R. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown SCREEWOPEN HOLE ��S �� .�.�,�..�.a�. ��.��.� � �,�.,��.� Screen irom ��j ro �q ft. Open Hole from to ft. WAYZATA, oesraucnoNs WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �No Obstruction Well owner s mailing address if tli8erent than properry ownei s address mdicated above. Type of Obstructions(Describe) Obstructions removed? ❑ Yes ❑ No Describe , PUMP ^ TYPQ �.�� 6EOLOf31CAL MATERIAL COLOH HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other - FORMATION If not known,inAicate estimated formatbn log trom nearby weli or bodng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists Y�� g�� ❑Annular space grouted with tremie pipe � �� ❑Casing Perforation/Fiemoval in.from �o tt. ❑ Perforated ❑ Removed . � in.from ro ft. ❑ Perforated ❑ Removed . Type of peRorator ❑ Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=501bs.) i�+�3�'�'�..A1�T� f��! £� � � Grouting Matenal from ro fl. yards bags from to R. yards bags from to ft. yerds begs irom to_ fl. yards bags REMARKS,SOURCE OF DATA,DIFFICU�TIES IN SEALING OTHER WELLS AND BORINGS ��, �.R�• �� t O I. and unused well or boring on property? ❑Yes �No How many? ryt�^+�y ��y��^�rtyp� }� LI O REGISTERED CONTRACTOR CERTIFICATION Al.�il[ �al.J1(fi!� �A� �iYL'.a ��i�a: �-i{l� This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation contained in this repoA is A'.C�: WI�TT�R I,.�'s11TEL T�K�N t 1 f�j� �� true to the best of my knowledge. �i�" C:t�€7� { f�-•-1 si�l k;.[i. k�,�i�+i�:It � 5C?NS# �LIaiG. 7;x�.3�t.� SE A L E Q Contractor Business Nam ��^ License or Registrefion fio. According to MN State Regulations � � �'�� Authonz re ntative Signature Date �1'.s��:.� .��.��.'��a��J�{�x��..� ��p�"�' ;�_-�t 'e��Y H �.6 9�7 9 Name o/Person Sealing Well a Boring