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_ v,��-�,�. <br /> , : _ . <br /> , _ ._._ .__ _ ._, � . _ w__. ._ :,� �_.. . w.�. _ .. ,_ ._ <br /> : �,.. .. .. :_ � . . ,x ,. .. .: _ , �; � <br /> wEL�OR BORING LOCnT1oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I f��� � <br /> County Name <br /> WELL AND BORING SEALING RECORD Minn'e oNa Unique Well No. L <br /> � �� Minnesota Statutes,Chapter f031 or W-series No. <br /> pm.e o�a�a�o.�> <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Construded <br /> �rono fl 7 23 07 ,. ',. ',. 12 f1 t�G C.� <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing z� ft. Original Depth ft. <br /> Longitude degrees minutes seconds p FER(S) STATiC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Multiaquiter <br /> WELUBORING Measured ❑Estimated <br /> 7 �Water Supply Well ❑Monit.Well t <br /> Show exact location of weil or boring ketch map of weli or boring � � <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other ft. below ❑above land surtace <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> -Y' ,./ <br /> �p Steel ❑Plastic ❑Tile ❑Other <br /> ♦� <br /> W —�- - -- - -- --;-- E WELLHEAD COMPLETION <br /> Outside: ❑Well House Inside: ❑Basement Offset <br /> -�-- ---- -r- --i-- � `,� <br /> � �meM �Pitless Adapter/Unit ❑Well Pit <br /> --�- -i— -i-- --�-- I <br /> 1 ❑Well Pit ❑Buried <br /> S <br /> �--�^"»—� ❑Buried <br /> PROPERTtY�.O,�WNER'S NAME/COMPANY NAME CASING(S) <br /> �.t u)i18t�l1Ct�� Diameter i Depth � Set in oversize hole? Annular space initially grouled? <br /> Property owner's mailing address if different than well ocation address indicated above �,�f <br /> � in.from Q to�'���ft. ❑Yes �No ❑Yes �No ❑Unknown <br /> 87� I,1H18�C.� I�Siik.' <br /> in.ffOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Eden Prairfe, N�T 55347 <br /> in.frOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAMEICOMPANY NAME SCREEWOPEN HOLE <br /> -7 f.` 7 I <br /> Well owner's mailing address if dittere�t than properry owner's address indicated above Screen from t0 ft. Open Hole from 4 � t0�ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe!- 1�1��� �-(/'"� �` ��n"� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ NO Describe � <br /> FORMATION <br /> Ii not known,indicata estimated formation log from nearby well or boring PUMP /} <br /> Type ��� t'v(7't�7 <br /> a�ifc o �s <br /> Removed p Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � C�Jo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material�L�� �-���T from Q to SS_�L R. yards LS�.� bags <br /> from to ft. yards bags <br /> (rom to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING pther 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 Minnesota Rules,Chapter 4725.The infortnation contained in this report is <br /> tme to the best of my knowledge. <br /> Ibn Stodola Well Drillfn� Co,. Inc. 27172 <br /> Contractor Business Name License or Registration No. <br /> _ �-I�-{35 <br /> _f,. <br /> Au ri d Representative 'nature Date <br /> �oca�coPv <br /> H 3���►� �+ ster�ec <br /> Name of Person Sealing Well or Boring <br />