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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � �� ^� � /� <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. � L} <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> I�r�r�e in «ea�a b�a�k,�o,k�aw�> <br /> Township t�ame Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Cons[ructed <br /> �`rono 117 23 21 i� S�`� ]�tTi �� <br /> GPS LOCATION— decimal degrees(to four decimal places) / <br /> Depth Before Sealing Z,�� ft. Original Depth ft. <br /> Latitude Longitude <br /> A UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer d /�� <br /> 271� v?�.l" �V� �CC}L10 55331 W LL/BORING Measured ❑Estimated Date Measured��1��' �.I'T� <br /> ' 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 ❑Env.Bore Hole ❑Other ��ft. �below ❑above land surface <br /> N lin , -,and buildings. CASING TYPE(S) <br /> , � , <br /> --'--- - � ---`-- ---'-- o <br /> -'--- <br /> ; ; j j tiy,,a-`� Steel ❑Plastic ❑Tile ❑Other <br /> --�-----'--- ---�-- � ''y WELLHEAD COMPLETION <br /> W ; ; ; ; ET . <br /> Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> 'h Mile �Pitless AdaptedUnit �uried ❑Well Pit <br /> --�-----T— ---;-----�- uried <br /> - ❑B <br /> �"`�.,, []Well Pit <br /> 1 ' S ' , �'�- ❑Other <br /> �-1 Mile� �' -�:.i�,q � .�i� ❑OthOf <br /> �... ."J."t„''� <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> �tanle - `�unkel�ri Z Diar�e��� �r Depth�� � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above y in.from� to ft. ❑Yes ,�No ❑Yes ❑No ❑Unknown <br /> 630fi Fden Pra�rie Rd r in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Eden Prairie, M�.T 5534b <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 ditterent than property owner's address indicated above Scre2n trom ���� to ��, ' ft. Open Hole f�om to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)�,,,f A/,d1�I�. �j—� 4 �(J�/f� <br /> 1 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP � <br /> ` Type `7V� �U�� <br /> -"'`� � � Removed ❑Not Present ❑Other <br /> �..� METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? �]Yes o TN# <br /> GROUTING MATERIAL(S) (One bag af cement= 4 Ibs.,one bag of bentonite-50 Ibs.) <br /> /✓�A%�L�!?��T '� � � <br /> Grouting Material from� to�t 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,DIF L Other unsealed and unused well or boring on property? ❑Yes�No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> MAY 0 91016 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 /> C►lY OF ORONO Licensee Busine�ss Na�m�0�1 t�Te1Z Drillfn�; �i0�• 11�• <br /> License or Registration No. <br /> ,... A �; . / t.�� � I' �l,lJ -- <br /> y::. �' ! <br /> Ce�ed Representative Signat e Certilied Rep.No. Date <br /> �_.� <br /> " � 3 ��9� �� <br /> LOCALCOPY '�,,'y.v.`", . ;�y E ��Y°�. <br /> Name of Person Sealing Well or Borinq� <br /> HE-01434-14 ID#53159 . 5n3R <br />