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wELL OR eORING LOCATiON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 115 6 6 5 <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique No. <br /> Henne i n Minnesota Statutes,Ch2pter 1031 or W-series No. <br /> P (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Oro�fl 11? 23 3 % % % ����9� <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 18L� FV�C Street, �Iayz�ta DepthBeforeSealing J�� tt. OriginalDepth ft. �/� <br /> O <br /> Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property �Single Aquifer ❑ Multiaquiter q <br /> lines,roads,and bulldings. C � `��•� <br /> N WELL/BORING �Measured ❑ Estimated ��� � `.�, <br /> � �Water Supply Well ❑Monit Well � <br /> - - - - -;-- — — �� �iC� ��'f <br /> ❑ Env.Bore Hole ❑Other ft. �]below �/ <br /> ❑above�suAace <br /> n <br /> W --f- -i-- -i-- --i-- E CASING TYPE(S) . <br /> I I I 1 vy� <br /> --�- -�-- -�-- '-�-- � �Steel ❑ Plastic ❑Tile � Other <br /> b mile <br /> --�- -�-- -�-- --i-- � CASING <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> LLL""" S 1� <br /> y�---r miie--�e � in.from_1� to� ry. ❑ Yes `„�No ❑ Yes ❑No �] Unknown <br /> I I <br /> PROPERTY OWNER'S NAME in.from to R. ❑ Ves ❑No ❑ Ves ❑No ❑ Unknown <br /> Properry owners mailing address if different than well location address indicated above. in.from to tt. ❑ Yes � No ❑ Yes ❑ No ❑ Unknown <br /> IB�O FOX 3treet SCREEWOPENHOLE <br /> Wayzata, MN 5539I�9��� Screenfrom to ft OpenHolefrom�ro s-'�f}`'_ ft. <br /> OBSTRUCTIO WDEBRIS/FILI <br /> WELL OWNER'S NAME <br /> ❑ Obstruction ❑ Debris ❑ Fill � No Obstruction <br /> Well owner's mailing address if ditte�ent than property owners address indicated above. Type of Obstruction/DebriS/Fill <br /> ObstructioNDebris/Fill removed? ❑ Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,intlicate estimated fortnation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material '�rom _r�� to�..��, ft. yards i�1 tt bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OP DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unseated well or boring on property? ❑ Yes � No <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 /> true to the best oi my knowledge. <br /> Stevens Drillin� b Env. Sezvi�es 86654! <br /> Contractor Business Name License or Registrallon No. <br /> �f�1�7 <br /> Autho�zed Representative Signature Date <br /> kichar� Stevens <br /> LOCAL COPY 115 6 6 5 Name ol Person Sealing Well or Boring <br /> H <br /> HE-01434-02 10/95R <br />