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_ <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota We!I and Boring 2 7 5 4 9 8 <br /> WELL OR BORING LOCATION Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 103I or W-series No. <br /> (Leeve blenk it no�known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> � �7V7 . <br /> t <br /> GPS Latitude degrees__. minutes_ ___ seconds Depth Before Sealing�_"���ft. Original Depth �� ft. <br /> LOCATION: Longitude� degrees______ minutes_ seconds <br /> A IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �ingle Aquifer ❑Multiaquifer /�/y� /� <br /> e��/� E� WE UBORING (�Measured ❑Estimated Date Measured Sf�I•'F '-✓� <br /> G(7`tV P� St Or �Nater-Supply Well ❑Monit Well 1 <br /> Show exact location of well or boring Sketch map of well or boring ,,J� �(� <br /> �. in section grid with"X." location,showing propert ❑Env.Bore Hole Other �L'Lft. �below ❑above land surface <br /> IinesyRoads and building �� <br /> � N � '� - � � CASING TYPE(S) <br /> --'--- --'--- ---`----'- � : <br /> � � � Steel ❑Plas[ic ❑Tle ❑Other <br /> --'----'-- ---`-- ---`-- � ( WELLHEAD COMPLETION <br /> w ; ; ; ; ET ,.. <br /> � � � � 'a Outside: �]Well House (_]At Grade Inside: ❑Basement Offset <br /> 'h Mile f�itless Adapter/Unit ❑Buried ❑Well Pit <br /> ; � : : 1 �z <br /> --;--- --r------------- <br /> ❑Buried <br /> ' S ' �1 weil Pit <br /> ❑Other <br /> �t Mile� � [,]Other <br /> �� <br /> PROPERTY OWNER'S NAME/COMPANY NA CASING(S) <br /> Diamet �/ � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if diflerent than well location add�ess indicated above � in.from� to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> �' <br /> 7`Kl7 ��ta B�� in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> St Louis Park, MN 55426 <br /> in.from to ft. ❑Yes ❑No ❑Yes [�No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � � <br /> Well owner's mailing address if diflerent than property owner's address indicated above Screen from !_�y�to�ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> �lods/Drop Pipe ❑Check Valve(s) � ❑Debris ❑Fill ❑No Obstruction ' <br /> �y. <br /> Type of Obstructions(Describe) �� _ �/�� � �V I�� __ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �_�s i�No Describe <br /> FORMATION — <br /> PUMP <br /> If not known,indicate estimated forma[ion log from nearby well or boring. /�. <br /> Type ��..)�` �V•+i0 <br /> dcift � 12 �emoved ��Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ir;Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> a Type of Perforator <br /> ❑Other —_--.- - - <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of ber}tonite=50 Ibs.) <br /> 1 <br /> Grouting Material ����`�����Mfim V to���ft. yards // bags <br /> from to ft. _ yards bags <br /> - ______ from_ ro ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Ycs o How many? <br /> � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. <br /> I!� Stodola Well Driliin� Co,. Inc. 1691 � <br /> Licensee Business Name "� License or Registration No. <br /> � I2-I2-08 ° <br /> i r entative Signat __ � Certified Rep.No. Date <br /> H 27549 8 J�° ��°"�" <br /> '•��"��Y ��Name ol Person Sealing Well or Boring � � � <br /> ,� HE-01434-11 IC#140-0423 --._... . ._.-.�. �._ 2ioaa � <br />