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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring � ������ � <br /> WELL Oii BORING LOCATION �yELL 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 /> Henne p in M1.�.�„�k��, —, <br /> Township Name Township No. Range No Sec�o o. F t n(sm.-►Ig.) Date Sealed Date Well or Bormg Constructec7 <br /> 4toao 117 23 � -0004 ',�`� /_�� G <br /> '� Numencal Street-Atltlress or Rre Number and Ctly oi Well or Boring Location ��'�^ / � <br /> 2 V U 5 N Shore Dr, OL 011� 5 5 391 Depth eetore Seaimg�__it Orig�nal Depth ��� n <br /> Show exact loc n of well or boring Sketch map of well or boring qOUIFER(S) STATIC WATER LEVEL <br /> m�seetiongriQwith"X'. location, showing propeny �OlSingle Ayuifer ❑ Multiaquder <br /> lines,roads,and buildings. <br /> N WELUBORING Measured ❑ Estimated <br />� � � � � � Water Supply Well ❑MonA.Weil �/ / <br /> ❑ Ern.Bore Hole ❑Other _ � h. �elow ❑ above land surtace <br /> W --�- -i-- -i— --i— E �� � CASING TYPE(S) <br /> � ' <br /> ` � � as � <br /> � <br /> —�- ---- -i-- --�- � �� � �Steel ❑ Plastic ❑Tile �Other <br /> Ytmik � <br /> y —�- -�-- -�-- --i-- � \� CASING(S) <br /> �s��' Diamete�� Depth Set in oversize hoie7 Annular space initiaily grouted7 <br />�`� i miie ,�" ,,j�t' � in.from� to: f �J ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br />�' �— —�" ,�,j�,=�4 <br /> f PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> Property own r s mailing a ress i i ere an we I on address indlcated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> 2193Q Minnetonka B�Qd SCREEWOPENHOLE <br /> � , ,;_� . f <br /> E����$l a t� i71� 5 5 3 3I Screen from ro ft Open Hole from -'✓ � to� R. <br /> OBSTRUCTtONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obshudi <br /> Well ownels mailin addresa if OiHerent Man r owner's address indicated above. —j✓"��/'^ ��� 4� ���� <br /> g p oPeny Type of Obstructions(Describe) <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP �j � <br /> TY� �,'�C,, �l)� 1' <br /> OEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> N rat krawn,inOicete eatimated tormabon bg from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �lo Annular Space Exists <br /> �- � ('-- � - ,—� <br /> ❑Annular space grouted with tremie pipe <br />�. <br />� ❑Casing Perforation/Removal <br />� <br /> in.trom to fl. ❑ PeAorated ❑ Hemoved <br /> in.from �o h, ❑ Perforated ❑ Removed <br /> Type of peAorator <br /> ❑ omer <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> f <br /> i_ Grouting Material �����//�`� � to� it. yards �S begs <br /> irom to ft. yards bags <br /> from to fl. yards begs <br /> hom to__ ft. 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 many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information conteined in this report is <br /> true to the best of my knowledge. <br /> �.,,�;�.,, . <br /> I3on Stodola tdell Driling Co. , Inc. 27172 <br /> Contracror Business N e �,- /,� License or Registration lio. <br /> `) � �i �--`c"` --'� �- ..1 <br /> '.aV �-- � ----�'� �-� �<o.J ,�..a,. <br />�'� ,„ �ai-' �t��. .` A tative ignafure . Date <br /> t- _ <br /> �. r'"„e'� (� ��� <br /> ����✓ ._._..v � /'--'r.�--�"-"'i-'�"d1'd�w-�- <br />� ������ �"� 18 5$5 5 Neme o�Person Seali�W Bonng <br /> _� <br />