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. _._. : . _ . .. .. . . .. .q,. _ . . ._ . . <br /> r. .. .ti.� � . a= -.... .;... <br /> MINNESOTA DEPARTMENT OF HFALTH M�nnesota Well and Bonng � ■ � r wn��� � <br /> WELL OR BORING LOCATION i � /� �( <br /> WELL AND BORING SEALING RECORD Sea�ing rvo H <br /> County Name Mmneso!a Unique No. <br /> Nennepin Minnesota Statutes,Chapter 7031 or W-senes No �_ � <br /> ILeave b�ank il no�known) <br /> Township Name Township No. Range No. Secuon No. Fraction�sm.-s Ig.) Date Sealed Date Well or Bonng Construded <br /> Orona l I 8 23 36 � '� ,f f.�C� 9�} <br /> Numencal Sireet Adtlress or Fire Number and City of Well or Bonng Location � � � ! <br /> �75 Ferndale Ra$E� North, Wayeat 4��Pi�OreSealing � "' _N. OnginalDepth /� N <br /> Show exact location of N•ell or boring Sketc�map of well or oring AOUIFER�S) STATIC WATER LEVEL <br /> m section grid wrth"X`. location, showing p rry �Single Aywfer ❑ Muhiaquiter <br /> lines,roads,and buil <br /> N �-- WEIUBORING Measured ❑ Esumated <br /> � � �� Water Supply Well ❑Monit.Well � <br /> � ❑ Env.Bore Hole ❑Other _ ��! R. � below ❑ above land surtace <br /> � � � �! <br /> W —�- -?-- -�-- --;— E -� CASING TVPE�S) <br /> � � <br /> �� <br /> � � � � � �. <br /> -�-- -'-- 'r:- Steel ❑ Plastic �Tile �Other <br /> i � 'i" '_�_' � � � <br /> u mde � ��. �� <br /> --�- ' ' ' � ._. �,.� CASING <br /> -�-- -�-- --i-- <br /> Diametey Depth / Set in oversrze hole7 Annualar space ini6ally grouted? <br /> S , � �,i <br /> �" Ves No ❑ Yes ❑No ❑ Unknown <br /> �i mi�e—{. '�'�_.. m.irom � to � ft. ❑ � <br /> i <br /> PROPERTY OWNER'S NAME in.from ro fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Jim b Mea� en Da to <br /> PropeAy owner'S mailing atldress rf tllHerent than well loca6on address indicated above. in.hom to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> �d4-2553 SCREEWOPENHOLE r � <br /> Screen from to ft. Open Hole irom `�� ro ��� ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑Debris ,❑y'�Fill ❑No Obst/r�y�tion <br /> Well owner's meiling address if diflerent tl�an property owner's address indiceted above. Type ot ObslruCtionS(Describe) ��"' " /'� � " f��Y���1 <br /> Obstruclions removed? �/J`Yes ❑ No Describe <br /> PUMP <br /> 5���= ('umr <br /> TY� . <br /> OEOLO(i1CAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If rat krawn,indicate estimated formatbn bg trom nearby well or bonng. MET OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � � �No Annular Space Exists <br /> ��� /� ❑Annular space grouted with tremie pipe <br /> f � ❑ Casing Pertoration/Removal <br /> in.irom to ft. ❑ PeAorated ❑ Removed <br /> in.from to fl. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ omer <br /> GROUTING MATERIAL(S) <br /> r / � <br /> /_i l�<;.��tf�'� � ,F � /� <br /> Grouting Material �'� from to fl. yards bags <br /> trom ro ft. yards bags <br /> from to tt. yards begs <br /> from to-- ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property7 ❑Yes �YJo How many? <br /> {J��' �;,.�,f f�-' �,} ,. �/ 1 �;:f ; LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> jJ' Fi"� b <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation conteined in Mis repat is <br /> 7'^`�i�f i( . ,, -7 ) r _ true to the best of my knowledge. <br /> � . -/ /1f <br /> ` "`-' � �~ DON STODflLA WELt DRILLING C�, , INC. �7172 <br /> / ��� � / �� � Contractor Busine�ame . . Licgnse w Registiation I'ro. <br /> 1..--�� �- � � r �..� � ��, , _ . <br /> �- 'L1���- � � _ , 4 <br /> , <br /> � ,n� , <br /> . � , ..� ����� ,�" „�.,� � f''r::.� � ''! ^'�• <br /> Authonzed Representative Signature Dete <br /> � <br /> "...., �a�} �' ',. ' •' •. �`. <br /> �../\.^1-y.. .._�. <br /> Name o/Person Sealing Well or Bcring <br /> �oca�coPY H <br /> HE-01434-04 $9$R <br />