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' � � � 274449 ' WELL OR BORING LOCATION MINNESOIh DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � County Name WELL AND BORING SEALING RECORD Menn'e90 a�Unique Well No. Minnesota Statutes,Chapter 1031 or W-series No. (Leava blank'ii no�known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed ��/ Nor� o , _ GPS Latitude _ _ degrees___ minutes___, _ seconds Depth Before Sealing �7�� ft. Original Depth ft. LOCATION: Longitude_ degrees_ _ minutes seconds ---�--- A U ER(S) STATIC WATER LEVEL - Numerical Street Address or Fire Number and City of Well or Boring Location r' �ngle Aquifer ❑Multiaquifer ��/ 1t�r�f 515 Fecndsle Rd N �F�� 55391 �W�L/�/BORING I�1M4easured ❑Estimated Date Measured �/-'/"� ��,_yNater-Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or bo ing J in section grid with"X." location,showing prope L�Env.Bore Hole ❑Other �� i ft. �elow []above land surface N lines,roads,and buildin CASING TYPE(S) ` --'--- --'------`----'-- I I�eel �� ❑Plastic ❑Tile ❑Other •�� --'--- --'--- --`- --- -- ELLHEAD COMPLETION _ : W : ; : : ET .,a - ,� W 'I __:___ __�___ __�__ __;__ ��Outside ell House , At Grade Inside: ❑Basement Offset : ❑W ��f � � , , , Miie �� ss A pter/Unit I_�Buried ❑Well Pit �f �tle da --.----,--- ---�-- ---:- 1 , S ❑Well Pit ❑Buried ❑Other �7 Mile� \� ❑Other J PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) � � Oiamet � Depth � Set in oversize hule? Annular space initially grouted? Property owner's mailing address if different Ihan well location address indicated above ��n.from � to � �/ft. ❑Yes �Vo [�Yes ❑No ❑Unknown 1$283 Mirmetonka B2ar1, St� B in from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown Iaeeghav�en,l�i 55391 in.trom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE , � Well owner's mailing adtlress if diflerent than property owner's address indicated above SCfeen ffOm�to /�� ft. Open Hole from to_ _ft. OBSTRUCTIONS - �ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction Type of Obstructions(Describe) ��//�'�/` /"Tl''� p �)__�'j� GEOLOGICAL MATERIAL COLOR HaaDNEss oR FROM TO Obstructions removed7 es ❑No Describe FORMATION _ If not k own,indicate estimated formation log from nearby well or boring. PUMP � Type— J V�� r�U M�.� � � :�Zemoved �Not Pres nt ❑Other_ _ METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: !,�o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. [j Perforated ❑Removed s :f in.from to ft [j Perforated ❑Removed Type of Perforator _ ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of be�tonite=50 Ibs.) ��,� /yy/� I Grouting Material r--• "" ��„�-'—from_ 0 to ,7�ft.____ yards /� bags from ro ft. yards bags from_ to ft. yards bags - � OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes o How many? LICEN5E0 OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best ot my knowledge. - Don Stodo2� �Jell bri2ling Cs�,. Inc. I692 _ — _-- -- - , Licensee Business Name License or Registration No. . , / / � � C r * _�- _ _.=- __ / y � j C i� esentative Signature `=' Certilied Rep.No. Date �� M1 . u �I , �� LOCAL COPY i n 2 7 4 4 4 9 I� Name ol Person Sealing Well or Boring -----_-- _ ---_ _-_ . HE-01434-11 IC#140-0423 vosa