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WELL OR BOFING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Bonng + ��O^�
�o���Y N�me — WELL AND BORING SEALING RECORD Sealing No H 1 L 1 �
Minnesota Unique No �
Minnesota Statutes.Chapter 1031 or W-series No.
i
Hennepin ILeave blank d not knownl �
Township Name Township No. Range No. Section Na Fraction�sm.�Ig.) Date Sealed Date Well or Boring Constructed
Osono 117 23 OS 1�ODU�� /r.;1 . �;,: `�' 'j
Numerical Street Address or Fire Number and Ciry ot Well or Bonng Location y
i
34 5 I.eaf S t, ��On� Depth Before Sealing _J -� R Original Depth �', __ft
Show exact locafion of well or boring Sketch map of well bonng A�UIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing roperty Single Aquiter ❑ Multiaquiter
lines,roads,and bwl ings.
N ___,_., WELUBORING �Measured ❑ Estimated
� � ' ' j � �Water Supply Well ❑MoniL Well
--�- -�----�-- —� � ! �%
'�' ❑ Env.Bore�Hole ❑Other _ �f"'� ft. �below ❑ above land surface
.__._.._. 1
W --�- - -- - -- --i-- E ' CASING TYPE(S)
� � �
� � �
� � � . ........_......... -,.
-�-- � ' • � -�f Steel ❑ Plastic ❑Tile �Other
--- --r- --�-- � , >
� I i mde � �.�
-�-- �-- � 4 ti\ � '. CASING
--- - --�— Y
� �,__ Diameter Depth Set in oversize hole? Annualar space initially grouted?
� {
�r�r m;ia—� ` _ '�l in.from '� to .R�`� fl. ❑ Yes �"No ❑ �es ❑No ❑ unknown
��n�Y��E��nM�ompany in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
Properry owner's mailing address if diKerent ihan well location address indicated above. in.from tp ft. ❑ Ye5 ❑No ❑ Yes ❑No ❑ Unknown
4i00 Berkahire Laae SCREEWOPENHOLE
Ply�outh 5 5446 Screen from �" to l�') ft Open Hole from to ft.
OBSTRUCTIONS
WELL OWNER'S NAME �'Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailin address if different than ro e owner's address indicated above. `" '� j
9 P P rtY Type of Obstructions(Describe) ��� •�"� i.% i i��� �
1 !
Obstructions removed? `�`Yes ❑ No Describe
PUMP
; y'.
TyPe �:,s
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other
FORMATION
It no�known,indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
,_�J � `� � No Annular Space Exits
❑ Annular space grouted with tremie pipe
❑ Casing Perforation/Removal
s
in.trom_ to n. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Ramoved
Type of pertorator
❑ Other
GROUTING MATERIAL(S)
i,
Grouting Material '`'�` �-"`��'from to f } (t. yards '" ba s
9
from to ft. yards bags
from to R. yards bags
from to__ ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEAUNG �r OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes �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 ot my knowledge.
Don Stodola We12 Drilling co. , iNc. 27i72
Contracfor Business Name �.. License or Registrallon 170.
, : /, „_
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�� /'y!�,' .. -c. �-�, /��� �i � . !
. 'A onred Representative Signature Date
� .. - . .,%�..i . -,t,i.l'!'`� tiw
LOCALCOPY H
12 9 0 21 Name ol PersomSealing Well or Bonng
HE-01434-03 2/97 R