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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 5 4�91 WELl�AN6�BORING SEALING RECORD Mennle9oa�Unique Well No. Minnesota Statutes,Cha ter 103i or W-series No. in p c�ae�e e�a�k��o�k�aw�i Township Name Township No.Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed ocmo 117 23 09 2�00'�9 '' f� �v U'7 , : Latitude de rees minutes seconds GPS 9 Depth Before Sealing 2� ft. Original Depth_ ft. LOCATION: Longitude degrees minutes seconds �FER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location �ingle Aquifer [;Multiaquifer �f�.r�L � 3 0$0 N o c t h S h o r e D r, n r� 5 S 3 9 I WEIUBORING �Measured ❑Estimated Date Measured ��' t+• 'Water-Supply Well ❑Monit Well � Show exact location of well or boring Sketch map of well or boring ? � in section grid with"X° location,showing property ❑Env.Bore Hole ❑Other _ ft. �below (]above land surface N lines,roads,and buildings. CASING TYPE(S) � � � � �.�,— � --'-----'--- '—"'--'- " Steel ❑Plastic ❑Tile []Other .'� --'--- --'--- ---`-- ---`-- '� WELLHEAD COMPLETION ' � w : : ; ; ET � - � � � � � Outside: �i Well House f]At Grade Inside: �asement Offset '� - '�4 Mile ❑Buried i,Well Pit .. --,--- --1--- ---=-- ----- _ itless A p dUnd ` Buried 1 �]P da te �, S U Well Pit ' , , ' :�1- ❑Other �--1 Mile—� - (� ❑Other ....,-_•�"+�.�.. PPOPERTY OWNER'S NAME/COMPANY NAME T CASING(S) Roberts Resiciential Re�nodeli 1(Z(,.'• Di� te�� ' Depth /' ' Set in oversize hole? Annular space initially grouted? Property owner's mailing address if di�terent than well location address indicated above �in.ffom c-Y to v�. ft. ❑Yes �No ❑Yes ❑No [�Unknown 2'999 W Cty Rd 42, Ste It� in.from to ft. ❑Yes ❑No ❑Yes ❑No �]Unknown Burnsville, A4�T 55306 in.from_ to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � 4 Well owner's mailing address if diflerent than property owner's address indicated above SCfeen ffom �`� to�� ft. Open Hole from to ft. �O/BSTRUCTIONS ' y�,Rods/Drop Pipe ❑Check Valve(s) ❑Debris [��Fill ❑No Obstruction i Type of Obstructions(Describe) r/U.lJ�r�-- �.L�� 9�"_� GEOLOGICAL MATERIAL COLOR HnaDNEss oR FROM TO Obstructions removed? �Yes ❑No Describe FORMATION PUMP � If not known,indicate estimated formation log from nearby well or boring. � I TyPe ..: CJ� i CJ i-; !`^�� Q "� � �Removed ❑Not Prese t ❑Other METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: .No Annular Space Exisls ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal ; in.from to____ __fl. ❑Perforated ❑Removed i in.from _to _ft. ❑Perforated ❑Removed Type of Perforator n Other _ _ ____ 1 GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) /� � �7 � GroutingMaterial ��~� ��f��from� 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 Other unsealed and unused well or boring on property7 []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. Don Stodola t+�ell Drillic�g Co,. Ine. 1fi91 Contractor Business Name License or Registration No. �..� � /��" y � �„ /� d: � I Certified R prese�t2}iira' ignature Certilied Rep.No. Date LOCAL COPY H 2 5�9 91 �'W~ ��:�:/""`-j�``•—J Name of Person Sealing Well or Boring � HE-07434-09 ICn 140-0423 s/osR