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� <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i ���r��� � <br /> WELL AND BORING SEALING RECORD Sealing No. H ;� <br /> Counry Name Minnesota Unique Well No. — <br /> Minnesota Statutes,Chapter 1031 or W-series No. � I <br /> �i�nnep i n �.�,.d,�„�k�.,,, _J <br /> Township Name Township No. Range No Section No. Fracuon(sm.-►Ig.) Date Sealed Date Well or Bonng Construdetl <br /> �rono 117 23 07 k4-0�l3 ''f Uit„i� C�/ <br /> Numerical Street Address or Fire Number and City of Well or Bonng Location � <br /> 4101 Highwood Bd, flro�o P 9-_��— 9 P '`� <br /> De th Before Sealin R On inai De ih _i N <br /> Show exact locafion of N�ell or poring Sketch map of well or bonng Aqy11FER(S) STATIC WATER LEVEL � <br /> in section grid with"X'. location, show+4(,� propeny D�Single Ayuiter ❑ Multiaquder <br /> { � ,� lines,ro s,and�puil gs <br /> N �"'S _ :-�_������� '1� � WE�UBORING Measured ❑ Estimatetl <br /> �cj Water Supply Well ❑Monit.Well � <br /> � ❑ Env.Bore Hole ❑Other _ _ �� ft. �below ❑ above land suAace <br /> W --�- -i-- -i— —i— E � CASING TYPE(S) <br /> � � � `h, <br /> \ <br /> -;-- --;-- -;-- --�-- � �,}g'r Steel ❑ Plastic �Tile �Other <br /> Ylmile <br /> —�- -i-- -�-- --�-- I CASING(S) <br /> � Diamete j� Depth /`. � Set in oversize hole7 Annular space initially grouted? <br /> � S � 0 �v Yes �No Ves No Unknown <br /> i miie� m.from to fl. ❑ ❑ ❑ � <br /> PROPERTV OWNER'S NAME m.irom to fl. ❑ Yes ❑Na ❑ Yes ❑No ❑ Unknown <br /> Y <br /> Propeny ownei s maili g address if d erent t n well location address indicated above. m.hom to ft. ❑ �es ❑No ❑ Yes ❑No ❑ Unknown <br /> '�f'f 1� Sho re 1 i ne Dr SCREEWOPEN HOLE � <br /> S�ring Park, MN 55384 ' �c <br /> 9 5 2-4 71-fl 5 32 Screen from�l��o� ft Open Hole from to n. <br /> oesrRucnoNs <br /> WELL OWNER'S NAME � Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction . <br /> Weil owner's mailing address if diflerent Man properry owner's atl0�ess mdicated above. Type o(Obstructions(Describe)�-i'�'�G�"! ����✓ g ������``"��� <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP <br /> TY� r,`► (�'G K,_r �(,+l� � <br /> GEOLO(iICAL MATERIAI COLOR HARDNESS OF FHOM TO �Aemoved ❑ Not Present ❑ Other <br /> FORMATION <br /> If not krawn,inOicete esGmeted formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � (� �.No Annular Space Exists <br /> {.__ t.�. i� ..i 7 <br /> ❑Annular space grouted with tremie pipe <br /> `�� ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> in.from to n, ❑ PeAorated ❑ Removed <br /> Type of pertorator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> .�..�- � <br /> Grouting Material ��������NlFom � to� ft. yards � bags <br /> from to ft. yards bags <br /> from to ft. yards begs <br /> from to__ fl. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many7 <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The intormation contained in this report is <br /> true to the best of my knowledge. <br /> Don Stodols Well Dri33fag Co. , Inc. 27172 <br /> Contraaor Business N me Liaense a Regishalion�10. <br /> � - 1� � � <br /> m ed ePrese�rerrve s�y�erure- oere <br /> ./`v". . ,._ `..y�,,,�./! st:„� 4 ,.f'�-.��`Y�"e� <br /> H w /ti/���n Name o!Person SeaFng Well or Boring <br /> L 7�'�i.i:e�;�,.�, f s j�.� V <br />