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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 35220 2 Sealing Minnesotao W ELL AND BORING SEALING RECORD County Name Unique Well No. Minnesota Statutes,Chapter 1037 or W-series No. • .2 :i C Hennepin l -......, r' ..� .1. Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed ordliao 117. 23 04 NE SE SW /f /261/7/7 1 6 - 1 • l > 7 7 GPS LOCATION-decimal degrees(to four decimal places) / ) r_ l I Depth at Time of Sealing !/".,`7a2 ft. Original Depth / -I ;�C ft. Latitude Longitude IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer 3060 FBrvieWLane, OCOtO 55356 WLUBORING Measured Date Measured'�I7 = Mr" ❑Estimated Water-Supply Well ❑Monit.Well /y/^. Show exact location of well or boring Sketch map of, • .r boring in section grid with"X" locatio0 property ❑Env.Bore Hole ❑Other /C..., ft. Ntf below ❑above land surface N lie orfFTi;•buildings. CASING TYPE(S) Steel ❑Plastic ❑Tile ❑Other '-- f-- WELLHEAD COMPLETION W ;_._ _r__ T i__.E I Outside:XPitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset Mile Well Pit ❑Buried ❑Well House 1 >r/ ❑Other ❑Well Pit 7-s , F--1 Miley ❑Buried {.;n.."r.,,,._._..".. .. k,.P_.-r'.. ❑Other PRiiitiv 0 N R'S NAME/COMPANY NAME CASING(S) rtx Property owner's mailing address if different than well location address indicated above Diam eI Depth Set in oversize hole? Annular space initially grouted? f'in.from__‘) to ft. ❑Yes ❑No ['Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes El No ❑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 / to f J Z.` ft. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill XNo Obstruction Type of Obstructions(Describe) HARDNESS OR GEOLOGICAL MATERIAL COLOR FORMATION FROM TO Obstructions removed? ❑Yes ❑No Describe If not known,indicate estimated formation log from nearby well or boring. PUMP !'l/y} >f Not Present ❑Present,Removed Prior to Sealing ❑Other Type / METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE y��/!�o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ElCasing Perforation/Removal Casing Diameter in.from to ft. El Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? ❑Yes"(No TN# GROUTING MATERIAL(S) (One bag of cement a 94 lbs.,one bag of bentonite=50 lbs.) t / Grouting Materialilegre l from 0 to/S-2. ` >fJ ft. yards /Z. 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 property? 17Yes YI 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 Well Drilling Co,. Inc. 1691 Licensee Business Name License or Registration No. e ' re ati a Si;d0..". t e Certified Rep.No. Date LOCAL COPY 11352202 �-ti-._.,-. - ).---1-).---1- _.tt,-_,- -41-4--1—.......�Name of Person Sealing Well oc fforing HE-01434-15 ID#53159 8/16R