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�� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 0 5 6 8 3
County Name
WELL AND BORING SEALING RECORD MennfesoNa Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
,f.� (�eave blank it nol knownJ
�Towns ip ame ownship No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed
�`
� GPS Latitude degrees minutes seconds � � :.
LOCATION:
Depth Before Sealing ft. Original Depth � ft. ��
Longitude degrees minutes seconds ppUIFER(S) S7ATIC WATER LEVEL
� Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑MWtiaquifer
2(7�0 Pheasant R.d Or�Ll� 55331 WELUBORING �Nleasured ❑Estimated
�ater Supply Well ❑MoniL Well � /
�� Show exact location of well or boring Skelch map of well or boring '/
� in section grid with"X" location,showing property ❑ Env.Bore Hole ❑Other �' ft. f7�below ❑above land surface
r�
N ads,and buildings. CASING TYPE(S)
�A.
s Steel ❑Plastic ❑Tile ❑Other
�
W —�- - -- - -- -- -- E � p�� WELLHEAD COMPL.ETION
.. , i ; ; la/ `C
� � � � � � Outside: ❑Well House Inside: ❑Basement Offset
--- �-- -;- --�-- �1 {
�: 1 �+^"� � ❑ PitessAdaptedUnit �Mlell Pit �
, -�-- -;-- -�-- --�-- I ts �`
S � ❑Well Pit ❑Buried
S
. �r.--7 mM�
� ❑Buried
PROPE TY OLW+N2ER'S NyAME/COMPANY NAME CASING(S)
B0� P 1 t C tl Co n s t ruc t i on Diam t�r� Depth � � Set in oversize hole? Annular space initially grouted?
Property owner's•mailing address if different ffian well location address indicated above
� in.frOm� to ft. ❑Yes [�lo ❑Yes ❑No ❑Unknawn
11725 54th Ave N
Plymouth, MN S 5442 in.from to ft. ❑Yes ❑NQ ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE f
Well owner's mailing address if diflerent than properly owner's address indicated above Screen from �� .t0�ft. Open Hole from 10 1t.
OBSTRUCTIONS
�ods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe) �/UI�I�� �r/-^� ¢" �Ur`//'"
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 2S ❑ NO DOSCIIb2
FORMATION
If not known,indicate estimated formation lop from nearby well or boring PUMP
�` Type �� i U m �
« �Removed ❑ Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
Li�vo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
/!
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one ba/g o��f bentonite=50 Ibs.) /'�
Grouting Material���1� �-�_��/����frnm ✓ to S„15.1 K./ yards �L bags
trom to tt. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or borin on ro e � �
g p p rty. ❑ Yes o How many.
LICENSED OR REGISTERED CONTRACTOR CERTIFLCATION
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
� Don Stodala Well Drillin,� Co„ Inc. 27172
Contracfor 8 sine s Name License or Registration No.
� -�- � �/ C'r�
z epresentative Signatwe Date
\�:�,y,y� t�.��,�,.�
LOCAL COPY H 'n� ,�,�Q�
Name o/Person Sealing Well or Boring