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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I �'�}'� X� � County Name . WELL AND BORING SEALING RECORD Minnle90 a�Unique Well No. ' s¢ Minnesota Statutes,Cha ter 103I or W-series No. P (Leave blank il nal kn wn) Towns ip a Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed � �� / c GPS Latitude degrees minutes seconds Depth Before Sealing � G.�� _ft. Original Depth _______fl. LOCATION: Longitude__ degrees minutes , seconds pQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well�or Boring Loca'tioLn ��Single Aquifer ❑Multiaquifer -��f,/y�/ A ,r1 4415 North Shoce Dr, Orano 5 J�C�! WELL/BORING i�Measure f ❑Estimated Date Measured .�Y�!►'_`i�`r 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 pro erty u Env.Bore Hole jJ Other �ft. [�low [;above land surtace 1 ` ines,roa and�ui s. N ,1;�:+_J.�-. ..__�._,.,�..... �,,. . CASING TYPE(S) �� ----- -------- -- --- -- � �teel ❑Plastic [j Tile ❑Other ,------------,— ; ; , � \ l� --'-----�--- ---�-----�- �y1 j t WELLNEAD COMPLETION W ; ; : . - ET ( _ _ �__ _;____; _�_ ! Outside: �]Well House ❑At Grade Inside: ❑Basement Offset '/.Miie !�Pitless AdaptedUnit ❑Buried ❑Well Pit -- - -- 1 '' � ❑Buried ❑Well Pit I S ' , ❑Other ��nniie� �Other PR ERTY NER'S[p��qM��E/COMPA N CASWG(S) .�'��r �✓�++�t� ��_$ Diame �� I Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above G� � to_�1�_fL Yes IZNO [ Yes � No in.from [� T, ] i] ❑Unknown 7544 Wa�hingtan Ave S +�d�� uct tC�43(� _ in.from to ft. ❑'Ies ❑No i]Yes _]No ��Unknown 1 !'iti 1 in.from to ft. �1 Yes ❑Na ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � Well owner's mailing address if diKerent than property owner's address indicated above SCreen hom��[O��_ft. Open Hole from to ft. OBSTRUCTIONS I�iods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill j]No Obstruction Type of Obstructions(Describe) �Jt�/t�_./� /�Tl'"'� �^ / (,J� � GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? [�s ❑No Describe FOHMATION PUMP If not known,indicate estimated formation log from nearby well or boring. �� � TYPe— � � m --- A � j��. � �� Removed ❑Not Prese t ❑Other � ! METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: � No Annular Space Exists �Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to___._,___,_R LJ Perforated �]Removed �� in.from to ft. ❑Perforated ❑Removed " z Type of Perforator L]Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite-50 Ibs.) _ _� � A t GroutingMaterial/v'��C�,.ff/A'�` J`�Rrom� to� ft. yards�Q bags _ from to ft. yards bags ' _ ___._ irom__ 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? t LICENSED OR REGISTERED CONTRACTOR CERTIFICAT�ON 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. tk�n Stociola Well Drillic� Co„ Inc._ 1691 Licensee Business Name License or Registration No. ;�? ;:� ! ! C ed ep entative Signat Certilied Rep.No. Date �i. . � �,,�-_. LOCAL COPY H 2 914 9? ~�--� �- �^�-�.��`��-- -- Name ol Person Sealing Well or Bonng ', HE-07434-12 IC#140-0423 y si09a