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WELL OR EfORING LbCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H ����c�] <br /> County Name , <br /> WELL AND BORING SEALING RECORD Mnnlesoa�UniqueWellNo. C' ` <br /> Minnesota Statutes, Chapter 103I or W-series No. <br /> (leeve blank'ii not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> 28 23 3� .�� �'l� /Z �v , O� <br /> , <br /> GPS Latitude degrees__ minutes seconds Depth Before Sealing �� ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds p�p[�.FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location IGfSingle Aquifer �_�Multiaquifer �^� /�,.��/ <br /> �i� L�68� Lake Rd �/�,6�[1V WELUBORING �Measured ❑Estimated Date Measured --�� ��y � <br /> 1 Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring � Sketch map of well or boring <br /> in section grid with"X" � location,showing property ❑Em.Bore Hole ❑Other � ft. �J below ❑above land surface <br /> N `G_y lines,ro dc�aad�Ndild� gs. CASINGTYPE(S) <br /> --'--- --'-----`-- ---'- � <br /> �} �` Steel ❑Plastic ❑Tile U Other <br /> ; ; ; ; �,�r `-.��\ i <br /> -- --- --------- -- ----- 5�- '" • WELLHEAD COMPLETION <br /> � , � . <br /> W ; ; : ; ET .` „ <br /> __�_____;_____�__ __;__ �i ,i Outside: L]Well House ❑At Grade Inside: i�Basement Offset <br /> �1 <br /> , , , , 'h nniie itless A p UUnd ��Buried ❑Well Pit <br /> , , , , � U P� da te � <br /> —�--—T----%-- --�- <br /> ❑Well Pit ❑Buried <br /> S <br /> ❑Other <br /> �—1 Mile� � . ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASWG(S) <br /> � Diameter� Depth ' Set in oversize hole7 Annular space initially grouted? <br /> Property owner's mailing address if different Ihan well localion address indicated above � / / �, <br /> _,_�in.from_C to GL� ft. ❑Yes �o ❑Yes �]No U Unknown <br /> 620 Beaver Usn �� in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Wayzata, I� 55391 <br /> :;�� in.from to __ft. j�Yes [�No [�Yes �]No ❑Unknown <br /> WEIL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> �f�,, /•��,���/ <br /> Well owner's mailing address if different than property owner's address indicated above SCfeen from �-�+`s' to �" ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> i` <br /> Type of Obshuctions(Describe) 11[//�L� �� �' �4-� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> Type F"` <br /> �Removed ��Not Present n Other <br />� METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Femoval <br /> in.from to _ ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated �.�]Removed <br /> Type of Perforator <br /> �f Other____ _ <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> ,/� �,,,/��� I � <br /> Grouting Material��°./'7� /�/!/^NArom� to� ft._ yards bags <br /> from to ft. yards bags <br /> from to 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? ❑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 information contained in this report <br /> is true to the best of my knowledge. <br /> Don Stadole �te2l Drilling Co., Inc. 1691 <br /> Licensee Busi y s ame .. License or Registration No. <br /> ,..J; , ,.i � -f" .' ,, fr-13"'{)8 <br /> rti ied Representative Signature Certified Rep.No. Date <br /> �ac�,_�Q�Y H 27o2s7 J� ��� - - - <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-10 IC#740-0423 - 5/o�a <br />