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Home My WebLink Aboutwell info _ MINNESOTA DEPARTMENT OF HEALTH Minnesota We!I and Boring 2 7 5 4 9 8 WELL OR BORING LOCATION Sealing No. H County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Chapter 103I or W-series No. (Leeve blenk it no�known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed � �7V7 . t GPS Latitude degrees__. minutes_ ___ seconds Depth Before Sealing�_"��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 �ingle Aquifer ❑Multiaquifer /�/y� /� e��/� E� WE UBORING (�Measured ❑Estimated Date Measured Sf�I•'F '-✓� G(7`tV P� St Or �Nater-Supply Well ❑Monit Well 1 Show exact location of well or boring Sketch map of well or boring ,,J� �(� �. in section grid with"X." location,showing propert ❑Env.Bore Hole Other �L'Lft. �below ❑above land surface IinesyRoads and building �� N � '� - � � CASING TYPE(S) --'--- --'--- ---`----'- � : � � � Steel ❑Plas[ic ❑Tle ❑Other --'----'-- ---`-- ---`-- � ( WELLHEAD COMPLETION w ; ; ; ; ET ,.. � � � � 'a Outside: �]Well House (_]At Grade Inside: ❑Basement Offset 'h Mile f�itless Adapter/Unit ❑Buried ❑Well Pit ; � : : 1 �z --;--- --r------------- ❑Buried ' S ' �1 weil Pit ❑Other �t Mile� � [,]Other �� PROPERTY OWNER'S NAME/COMPANY NA CASING(S) Diamet �/ � Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diflerent than well location add�ess indicated above � in.from� to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown �' 7`Kl7 ��ta B�� in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown St Louis Park, MN 55426 in.from to ft. ❑Yes ❑No ❑Yes [�No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � � Well owner's mailing address if diflerent than property owner's address indicated above Screen from !_�y�to�ft. Open Hole from to ft. OBSTRUCTIONS �lods/Drop Pipe ❑Check Valve(s) � ❑Debris ❑Fill ❑No Obstruction ' �y. Type of Obstructions(Describe) �� _ �/�� V I�� __ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �_�s i�No Describe FORMATION — PUMP If not known,indicate estimated forma[ion log from nearby well or boring. /�. Type ��..)�` �V•+i0 dcift � 12 �emoved ��Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ir;Removed in.from to ft. ❑Perforated ❑Removed a Type of Perforator ❑Other —_--.- - - GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of ber}tonite=50 Ibs.) 1 Grouting Material ��`��Mfim V to��ft. yards // bags from to ft. _ yards bags - ______ from_ ro ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Ycs 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 of my knowledge. I!� Stodola Well Driliin� Co,. Inc. 1691 � Licensee Business Name "� License or Registration No. � I2-I2-08 ° i r entative Signat __ � Certified Rep.No. Date H 27549 8 J�° ��°"�" '•��"��Y ��Name ol Person Sealing Well or Boring � � � ,� HE-01434-11 IC#140-0423 --._... . ._.-.�. �._ 2ioaa � , ;� -. C�t�z L i 1 �l � � F,� ��„�; � ��,�3_ 32z � Z r -�-� � � � « � s a F. �, . r,. r1�:.�.� MfNNES�TA DEPARTMENT C1F HEALTH �� `�� , '.� WELL DlSCLOSURE CERTIFICATE ��'�Z� 3°� �`i�L� aes�xtwrp�cr�rairx PLEASE TYPE OR AR1NT ALL lNFORMATION 'Fill out r;epa�ate well informafion page if more than three welts are locefed on the properfy. WELL#1 � CQUNTY QUARTER(OR GOVERNMENT LOT) S�CTION NUMBER TOWNSHIP NUM9ER RANGE NUMBER Hennepin NW }�k- cJ� 4 117 23 WEL.L STATUS(Check only one box) YEAR WEL�WAS SEALED OR WELL IS; [] IN USE{1 j❑ NOT 1N USE(2)❑ SEALED BY LICENS�D WELL CONTRAGTOR{3) S�uirvGFtEGO�NUMa�R pF KNOWM (GaH MDH to verify sealing recard is on file.) ww�oF ucEr�v��t If ths well has been sealed by someone other than a li�ensed well coMrdctor or a COI�TFt,4CTOR licensed well sealing contractor,cheCk the well status as no!in use. WELL#2 COUNTY QUARTER(OR GOVERNMENT L0� SECTION NUMBcR TOWNSHIP NUMBER RANGE NUMBER WELL STATUS(Check only one 6ox) YEAR WELLWAS SF_Al.EO OR WELL IS� ❑ IN USE(1)�NOT(N USE(2j❑ SEALE�8Y LICENSED WELL CONTRAGTOR(3) SEALING RECORDNUMBER(IF KNOWN� (Call MDH to verify sealing record is on file.) NAM�OF UC�NSEO V+�ld. If the well has been sealed by someane other than a lic�nsed well contractor or a CwJrRnCTOR licensed well sealing contrach�r,check the weli sfatus as not in use. WEI.t,#3 COUNTY QUARTcR{OR GOVERNMENT L0� SECT(ON NUMBER TOWNSHIP NUMBER RANGE NUMBER WELt STATUS(Check only one hox) YEARUVELL WAS SEALED OR WE�L!S: ❑ IN USE(1)0 NOT 1N USE(�❑ SEAl.ED BY LICENSED WELL CONTRAGTOR(3) s�w��coRONunneEa pF ia,:owr�� (Cap MDH to vetify sealing record is on file.) �MEOFUCEN5EDINELL If the well has 6een sealed by someone other than a licensed we1!contractor or a ��'oR licensed wel!sealing contractor,check the well status as not in use. SKETCH MAP-Sketch the loca6on ot the well(s)and include estimated distancee from roads,streets,and buildings. IF MORE THAN ONE WELL ON PROPERTY,USE THE WElL LOCATION hiUMBER QBOVE TO 1DENTIFY F1�CW WELL. The locat;on of the wefl{s}must be provided. I(H►e location of a well is not known,have the welf iocated 6y a per�on qualified to lncate we!!s,such as a licensed well contractor. �1C�r�h, '�u�-h , £,�S r � �.� Sr �v QV1� �qV�.S'Z. x �� .S trfocmation providad on this form is classified ae public(ntormailon under Minnesota Statutes, Chapter 13. To request this document in another format call(651)215-0811 or TOD(65t)215-0707 or greater Minnesote through M;nnesota Relay Service a,1-80G-627-3529 and ack for{651)295-0811.V;si;our web site at www.heallh.state.mn.usldlvsJehiwells/disdosuresl HE-0'l1E7�J9 tp�taaoaas 7/02R � � �G Bb�9 �ON ��dbb�l 900Z �r.�� r