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R�+�E9�3�� <br /> �`� MINNESOTA DEPARTMENT OF HFA�TH Minnesota Well and Boring ���0�� <br /> WELL OR BOFING LOCATI . Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. �- <br /> Hennepin CITY 0�=(�� i'�i� Minnesota Statutes.Chapter 1031 or W-series No. :�J <br /> (Leave biank if not known) '�'� � <br /> Township Name Township No. Range No. Section Na FracUon(sm.�Ig.) Date Sealed Date Well or Boring Consiructed <br /> Oraao 118 23 36 41„-�4�Oi,. �,�/ �- <br /> Numerical Street Adtlress or Fire Number annd City of Well or Boring Location '' � <br /> 39 5 N Fe rndale ild] �rd�� 5 5 39 Depth Before Sealing � � tt Original Depth "� ft <br /> Show exact location of N•ell or bonng Sketch map of well r boring A UIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". � location, showing ra�rty Single Ayuifer ❑ Multiaqwfer <br /> lines,roads, Rd$ IcMgs. <br /> N . � WELUBORING Measured ❑ Estimated <br /> � � � � ,✓ ,.,.� Water Supply Well ❑Monit Well � <br /> i i '_i_" __� ...i �s �L <br /> � : �•- �* � ❑ Env.Bore Hole ❑Other _ ` fl. �G below ❑ above land surface <br /> I I I I — <br /> ! <br /> yy -- - - -- - -- -- -- E � ' CASING TVPE(S) <br /> � � � � <br /> � � � <br /> � � � � V � � <br /> -�-- -�- -�-- --�-- � 'i � � Steel ❑ Plastic �Tile � Other <br /> � � � � j z � , <br /> �.m�le `? -- <br /> ' ' ' ' ''�� ` CASING <br /> __L_ __i_ __J__ __J__ � ..... .�-.._ <br /> \ <br /> ` - � Diameter ,� Depih e Set in oversize hole7 Annualar space initially grouted? <br /> ,`.\ t '��� <br /> �r mne� �� .�,�l�t \' t�� in.from f-� to ��� ..i ft. ❑Yes �No ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> Bruce Bren Ii m <br /> Property owner's mailing address if ditterent than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> 10V S Broadrap SCREEWOPENHOIE � � <br /> WByZa ta� MN 5 5 391 Screen from C� � to ~� � ft. Open Hole from to ft. <br /> 4��-091$ OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Dro Pi e ❑ Check Valve(s) ❑ Debris <br /> p p ❑ Fill ❑No Obsiruction <br /> Well owner's mailing address if different ihan property owner's address indicated above. Type of Obs�ruCtions(DesCribB) ��j�f l��f � r-f/��! ��- �`�r'f f����I` <br /> Obstructions removed?,,�Yes ❑ No Describe <br /> PUMP <br /> i-.� _ ,,� .-,.`�. <br /> TYpe !�'�?r�,/� f.,s,.'1� I`: . <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> It not known,indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> dr i f t O ^A , No Annular Space Exits <br /> f� ❑ Annular space grouted with tremie pipe <br /> ❑ Casing PerforatioNRemoval <br /> in.trom_ to ft. ❑ PeAorated ❑ Removed <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> Type ot pertorator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) <br /> .. ,.��1.�.. ' � �-.. <br /> .if,"i1 i :, . . �,«% � i <br /> GroutingMaterial� from to .�`!t fl. yards bags <br /> from to fl. yards bags <br /> from to fi. yards bags <br /> from 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 CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesola Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> Don Stodola �Tell Drillin� Ca., Inc. 27172 <br /> Contractor Business Na e .. License or Registretion l�o. <br /> --.__ .. �- :'" .:.: . <br /> �i'�'�-- .,�>' ,-- ,�/,f. __. 10-15-97 <br /> ^�uthOAz'ed Representative Signature Oate <br /> Ji� Antonson <br /> LOCALCOPY H <br /> 12 9 0 5 3 Name ol Person Sealing Wel1 or Boring <br /> HE-01434-03 2/97 R <br />