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Minnesota Well and Boring <br /> MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 42991 <br /> WELL OR BORING LOCATION - _ <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Minnesota Statutes.Chapter 1031 or W-series No. <br /> Hennepin <br /> Keave blank d not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm. •1g.) Date Sealed Approximate Date Well <br /> or Boring Constructed <br /> 40 .V.10 117 23 5 33-(1934414 /2 Ca-- q3 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location 94 / .7/ / <br /> 332 II Lake St, I,cnT4ake, M Depth Before Sealing It. Original Depth9 ft. <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level S4ccurate <br /> in section grid with"X". location.showing property lines. <br /> roads.and buildings. ❑Approximate <br /> N \\ <br /> ' " <br /> _ <br /> J / <br /> . <br /> f. <br /> i 1 Single Aquifer ❑Multiaquifer below above land surface <br /> A ,_ CASING TYPE <br /> W E Y <br /> r + <br /> , r T <br /> � i Steel 0 Plastic 0 Tile 0 Other <br /> i :smile f <br /> I. <br /> S 3 Screen from `0 to / ft. Open Hole from to ft. <br /> He —t mile—'1 OBSTRUCTION/DEBRIS/FILL <br /> 0 Obstruction 0 Debris 0 Fill <br /> PROPERTY OWNER'S NAME <br /> Waters & Assoc. �( )ems <br /> Type of debris/obstruction <br /> Mailing Address if different than property address indicated above. <br /> Obstruction/Debris/Fill removed? 0 Yes ❑No <br /> 10340 Viking Dr, Suite 110 PUMP <br /> Eden Prairie,yeMN 55344 <br /> Attn: Blake ❑Removed plot Present 0 Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring" r <br /> c94 0 . in.from to. ft. 0 Yes , No 0 Yes 0 No ❑Unknown <br /> Drift in.from to ft. 0 Yes 0 No 0 Yes ❑No 0 Unknown <br /> in.from to ft. 0 Yes 0 No ❑Yes 0 No 0 Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists <br /> 0 Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> DEC �i "T":;;-93 <br /> Type of perforator <br /> ►+ ❑Other <br /> GROUTING MATERIAL <br /> / <br /> (El'1Krv�yv, QC/ <br /> Grouting material A„fill / from Q to / 7 ft. yards /)_. bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> a,�,, <br /> from to ft. yards bags <br /> Grouted 2” well 94' deep from to ft. yards bags <br /> 2 bags cement UNSEALED WELLS AND BORINGS <br /> 4lbs bentonite <br /> & Other unsealed well or boring on property? 0 Yes {]�(Jo <br /> 2men labor, rig cement grout pump LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Don Stoddla Well Drilling Co., Inc. 27272 <br /> Contractor Business Nar•e License or Registration No. <br /> f 1!0-13-93 <br /> � _ - � <br /> t 'e•-'-.rASSnt five Signatu!firre Date <br /> Jim Antonson <br /> LOCAL COPY H 42991 <br /> Name of Person Sealing Well or Boring <br /> _ ,kEoi454-m <br />