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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring Q��Q WELL OR BORING LOCATION Sealing No. H N eJ County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. x or W-series No. Henne lri Minnesota Statutes,Chapter 1031 «Qa�e e,a�k;,�o,k�o„�, Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed s Orono 118N 23 35 S�V SW� June 23, 2011 Unknown �atitude� degrees� minutes�L �econds De th Before Sealin 91 OCATION: Longitude� degrees� minutes P 9— 7� �t. Original Depth__. __ ft. �,seconds AOUIFER(S) STATIC WATER LEVEL Numerical Sireet Address or Fire Number and City ot Well or Boring Location �Single Aquifer U Multiaquifer 1190 Lyman Avenue, Wayzata 55391 ,�{WaerO-Supply Well ❑Monit Well �� easured I Estimated Date Measured Show exact location of well or boring Sketch map of well or boring G/ in section grid with"X." location,showing property L�Env.Bore Hole ❑Other _ _ ___. fc �3�ielow ❑above land surface N lines,roads,and buildings. CASING TYPE(S) � --'--- --J--- --`-----'-- .: _ �teel r]Plastic ❑Tile ❑Other_ _ _______ � --'--- --'--- -"�" "'`-- WELLHEADCOMPLETION �- W ; ; ; ; ET ,. � � _;____r_ �+ • Outside: ❑Well House ��- ❑At Grade Inside: �asement Offset �-� --�--- --_--- .� \� �� :�, ; , , , , 'F Miie � itless A p dUnrt ❑Buried ❑Well Pit � � ��'' �I P' da te , --,-- --;--- '-- ---.- 1 ' - ❑e�nea ' S j]Well Pit ❑Other F—1 Mile� '�,__J O[hBf PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) ' ' Palmer Diametel O Depth p L Set in oversize hole? Annular space initially grouted? _ Property owner's mailing address if different than well location address Indlcated above O V -�� in.trom to___,____ ft [,Yes ❑No ❑Yes ❑No �Unknown �, 52,� 111C11211 MOU11Cl StTeet� ft3B in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown Wayzata, MN 55391 in.from to ft. ,.��Yes ��No I_1 Yes �No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE Well owner's mailing address if different than property owner's address indicated above Screen from_ "V _to___�� ft. Open Hole from _to _ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �Vo Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obsiructions removed? ❑Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. C1�1�/ 17TOWI7 3 Type. _ J Removed ;,�Jot Present ❑Other Sand/Gravel/Cl y Grey � 7 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: f�No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Pertorated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator .,. �'Other ._ GROUTING MATERIAL(S) (One bag of cement_94 Ibs.,one bag of bentonite=50 Ibs.) Neat Cement 0 91 15 ' GroutingMaterial___ ___ ___ ,_ trom to ft. yards____ .__ bags from to ft. yards bags from to ft. yards_ bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING � �J�, o � Other unseaied and unused well or boring on property. Yes �i'�lo How many. _ . Geology From: LJN #778062 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 ta the best of my knowledge. E.H. Renner & Sons, Inc. 1431 � �� D __ _ __ _ _ _ Lice;<�Business Name License or Registration No. `'' ", � �e�� 467 10/7/11 �/�/�+�g --- - - -- -- . Lrt,rV�ding to MN Stat� Re�ulatiQr�s Certi/iedRepre ntativeSignature Certi/iedRep.No. Date —I Kevin Scheiterlein �o��o� H 292795 _ fi —_ .—_. _. _ —.. __ _. ...__- ..._.._ —. _— ____ __ __ . Name ol Person Sealing Well or Boring . ,HE-01434-12 IC#140-0423 s/OSR