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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I `� �'1�� County Name WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No. �j `� Minnesota Statutes, Cha ter 1031 or W-series No. ?IA��: i� P ��ea�e eia�k n no�k�own� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �rnnt� 117 23 �}7 S''Q S�� ? 1� /7�A/� J ry , GPS Latitude degrees minutes seconds Depth Before Sealing_L-r� _ft. Original Depth____ .__ ft. LOCATION: Longitude degrees minutes seconds A�IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location i Single Aquifer j_]Multiaquifer ��,,�L A�r, !�315 rTorth Shnre �rs '�r�nn rTrl�'�'.�'r W �ORING Measured ]Estimated DateMeasured �' r•�= =ri _ � Water-Supply Well '�.`,MoniL Well + Show exact location of well or boring Sketch map of well or boring t � in section grid with"X" c tion,sho in property ❑Env.Bore Hole [�Other � ! ft. �below ❑above land surface ? i ,roads�n�buddings. N CASING TYPE(S) � --'--- ---'------`-- --'-- Steel ❑Plastic (J Tile �Other � --'--- --�------`-- ----- ELLHEAD COMPLETION : � W � � � � �T '''�!!`````` __.____� W • ;___,.__ __;,__.�__ --- �� ' Outside: ]Well House :j At Grade Inside: ❑Basement Offset 'hI Miie I� I�Pitless Ada ptedUnit ❑Buried ❑Well Pit I � n Buried ' ' ' ' 1 .,]Well Pit 5 �--1 Mile-� �� []Other_ ❑Other_._ _. _ PROPERTTY OW1�NER'S NAME/COMPANY NAME CASING(S) �'� +r3 a. 4+L1$(L� js�1l�s Diame/Iey� � Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above L/ in.from to ft. Yes No � __ � � [� � U Yes ❑No �Unknown 15101 �tone Ridbe Trace in from_ �o ft. i ]Yes ❑No ❑Yes �f No ❑Unkr.own ��ayzata, PS�? 55391. in.from to ft. ❑Yes ❑No ❑Yes [_]No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE t /� Weli owner's mailing address if different than property owner s address indicated above SCreen from �,� to Z�(O ft. Open Hole irom to ft. OBSTRUCTIONS Rods/Drop Pipe ❑Check Valve(s) ❑Debris `Filt jJ�No Obstruction Type of Obstructions(Describe)�,l'tiN� �.Z�� ' �(/M� GEOLOGICAL MATERIAL COLOR HARDNESS OFi FROM TO Obstructions removed? Yes i� ;Na Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. n M['� Type�V 1^� �U!• 1 Y --- � �""' � ��' �Removed ❑Not Present ❑Other METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,Ofi CASING AND BORE HOLE: �No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ;]Casing Perforation/Removal in.from __to ft [_]Perforated ❑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.) /� ,y�� ''�' / � � GroutingMaterial�/�/ CF!/��< from d to 2�� ft. yards� bags from to ft. yards bags g 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 � o 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 af my knowledge. �vn St�iola ?�lell I�ril l tAg�o,' Tnr. 16�1� — ; Licensee Business me s� ,y Lic nse or Registration No. '` � � T�� -s�.-��- •� �� /.� ertfied Representative Signature Certified Rep.No. Date H � � . �,�....,) _��,-`.1 lOCAL COPY �1_ � �,� `�'� �J Name ol Person Sealing Well or Boring HE-01434-13 IC#140-0423 -� si�2a