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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 6 4 3 2 8 County Name WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. � �n Minnesota Statutes,Chap�er 1031 or W-series No. (Leave blank�it not known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Orcx�o 117 23 05 1�{IC1�5 '' -_�.� I I �,10� 7 '°� 4 GPS Latitude degrees minutes seconds Depth Before Sealing ��:a ..ft. Original Depth ft. LOCATION: Longitude degrees minutes seconds A�UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer I,.]Multiaquifer � � Y � � *�$� Rt �� ELUBORING �Measured ❑Estimated Date Measured � .___ LC J ater-Supply Well f�Monit.Well _ Show exact location of well or boring Sketch map of ell or ring ` - in section grid with"X° location,sFr g prop rry �.�Env.Bore Hole ❑Other �✓ ft. ❑below ❑above land surface lines,roadsP ar buildi s. N CASING TYPE(S) , ��.. : --'--- --�-- --`-----'-- �teel ❑Plastic ❑Tile ❑Other .___. ' --+-- --�--- ---`-----'-- �� WELLHEAD COMPLETION �� : W ; ; ; ; ET ; __;___ __,___ __�_____r__ 4; Outside: [.]Well House �f At Grade Inside: ❑Basement Offset �� 'h nn��ie ❑Buried [_'�Well Pit 1 ❑Pitless AdaptedUnit _ ❑Buried �' �]Well Pit S y �J Other �1 Mile� ��,�; I��Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) �I, Diameter Depth Set in oversize hole? Annular space initially grouted? ��- Property owner's mailing address if diflerent than well location address indicated above ��in.from� to�ft. ❑Yes '�1Vo ❑Yes ❑No ❑Unknown � � � � �t in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown Wayzata, I�;t 55392 2 of 2 gt�n: l��o� S��V in.from to R. ❑Yes ❑No ❑Yes ❑No ❑Unknown t7r" �J WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE /�� Well owner's mailing address if diflerent ihan properry owneis address indicated above Screen from�to�yLft Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe U Check Valve(s) ��Debris r�Fill ,�TVo Obstruction T s...' Type of Obstructions(Describe) ____________ GEOLOGICAL MATERIAL COLOR HARONESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe _ � FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. _ _ Type ❑Removed �Not Present ❑Other _ METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �lo Annular Space Exists IJ Annular Space Grouted with Tremie Pipe ,]Casing Perforation/Removal ! _____in.from to R ��Perforated '�,�Removed in.from to __ft. [�Perforated ��Removed Type of Perforator i �. ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) .:...' ,�� / 7 / .... . � Grouting Material./�''•?� �'•'�'--�°-=tc�hi C_/ to /�.1 ft. _ yards � bags from � to ft. yards bags from to ft. yards_ bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �Yes No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. Dcm SEodul.a 'W�Il Drflling Co,. Inc. I691 Licensee Business N me License or Registration No. ,� _ _ - / ' G tif ep�esentative Signature Certified Rep.No. Date H i.�4�28 `�` r �OCf;L CC�PY �.yi..- ;�i��,.f.�J`+'�'�'\..i Name ol Person Sealing Well o� HE-01434-10 IC#140-0423 .. sio�a . � �... <.. �;. ..,.,., , ,�.�. . ....�. , �. - . .......:. ......... . .....�. . . i . �..�. ,_ .,.s�r: . ...:.... . , . .:. . .> . .. .. ,. ,. , m..,..