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�- . . ._. ... . � . . Y ., . . . 9 _ . :��:��:.:.,..��:.. � � WELL OR BORING LOCATiON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Bonng I �� - � �1� FL AND BORING SEALING RECORD Sealing No �"� Counry Name �yA A� �, r� Minneso!a Unique No. � -- � L'�"e.'fIY"l�?plIl ��a '- Mmnesota Statutes,Chapter 1031 or W-senes No. (Leave b�ank i�not known� Township Name Township N�Ra�g�1 Q- $� on-,No. racuon�sm �Ig.) Date Sealed Date Well or Bonng Gonst�uctea ur�;�v i17 23 �"'� , ,. 3/i/99 Numerical Sireet Adtlress w Fire Number and City o�Well or Bonng Location .��{7 V �t�n�$ i,01 il� Lane OrJn� Depth Before Sealing �� ft Original Depth �7 n Show ezact locauon of v.�ell or boring Sketch map of well or bor�ng ApUIFER�S) STATIC WATER LEVEL � v in section grid with"X". N �. locahon, showing property ��ngle Aquiter ❑ MultiaquAer lines,roads,and buildings. N WELUBORING Measured ❑ Est�mated [.�.Water SupD�Y Well ❑Monit.Well Ct ❑ Env.Bore Hole ❑Other _ �v fl. TJ below ❑ above land suAace W --�- - -- - -- --i-- E � CASING TYPE(S) � � � � � -�- ---- -�-- - -i - � ' ; - --- [�.Steel ❑ Plastic �Tile � Other � um�re i y ._... . " . ',' -�- �- �1 - --�-- � t••----.i ._.. . _._�. CASING .. Dlameter Depth Set in oversize hole? Annualar space milially grouted? S � � �3 Ves No Unknown ��m,�� in trom to n. ❑ ves [�No ❑ ❑ ❑ � PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑Yes� ❑No ❑Unknown 1-suO i2lttvt Properry owner's mailing atltlress ii diflerent than well locafion address indicated above. in.irom to ft. ❑ �es ❑No ❑ Yes ❑ No ❑Unknown C�U K�1�li7X SCREEWOPEN MOLE 1�`.� La ke .S�`.r�v t ►'�Z�� Screen trom a� to �� R. Open Hole trom to R. �ayzata. .ry1�Y �5:331 oesraucnoNs WELL OWNER'S NAME Aods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction Well owneYs mailing atldress if tliHerent than proparty owner's adtlress indicatetl above. Type of Obstructions(Describe) r u��I F�1 l�� (�n a ��1 r�t'� Obstructions removed? �Yes ❑ No Describe PUMP Type ��rl�IG�r51b1� CiEOLO(i1CAL MATERIAL COLOH HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other FORMATION If not known,indicate estimated formation log trom nearby well or boring. ME�TyHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: L7'No Annular Space Exists II r 1�� y� ❑ Annular space grouted with tremie pipe � ❑Casing Perforation/Removal in.from �o k. ❑ Pertorated ❑ Removed in.tiom to R. ❑ PeAorated ❑ Removed Type of perforator ❑ omer GROUTING MATERIAL(S) Grouting Material ��r t'1'dI�Cl from �� to � R. yartls � begs from to R. yards bags from to ft. yards bags from to__ k. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER W ELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes �o How many? LICENSED OH REGISTEHED CONTRACTOR CERTIFICATION This well or boring was sealed in accordence with Minnesota Rules,Chapter 4725. The information contained in Mis report is true to the best of my knowledge. tL.:b ��.Ll L).fr1.I.l.1Lly L /L /C> Contracror Business Name License a R 'ha' fio. i _�+ '` :�' '�`T'--�� .�.,.. ,-�/�l .. /� .. i�.�., s'' _� / , ¢' ,/ AuMorized Repiesentative Signature Dere ��1. ....��. � �TdYf1�S TL�.'ti _ Name ol Person Sealing Wel/or Bonng � LOCALCOPY H HE-01434-04 8�98 R