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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring "ling No. 243236 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave Monk a not ab. <br /> Township Name Township No. Range No. Section No. Fraction(sm-e•Ig) Date Sealed Date Well or Boring Constructed <br /> QBlow 117 23 05 23-0027 'A r C- 05 <br /> GPS Latitude degrees minutes secondseo <br /> LOCATION: Depth Before Sealing ft. Original Depth ft. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location 'Mingle Aquifer 0 Multiaquifer <br /> 389 <br /> Westlake St, OLS 55356 [)WELLJBORING easured 0 Estimated <br /> (Vater Supply Well 0 Monit.Well , <br /> Show exact location of well or boring Sketch map of well or..'ng <br /> in section grid with"X" I. . .. 0 Env.Bore Hole 0 Other ft. ,slow 0 above land surface <br /> Ines, •ads,and buildin,s. <br /> N • CASING TYPE(S) <br /> • <br /> k <br /> sySteei 0 Plastic ❑Tile 0 Other <br /> W---r---,- --,-- , E WELLHEAD COMPLETION <br /> I <br /> Outside: Well House Inside: 0 Basement Offset <br /> Y <br /> 1 1 I I frtmr <br /> Z! 0 Pitless AdapterlUnil ❑Well Pit <br /> 1 i— i t I <br /> 0 Well Pit ElBuried <br /> Ir'—r milt--4 ,y5C1 0 Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> PobPrt Rricksnri Diameter Depth t Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address it different than well location address indicated above <br /> �,.!__ 2. In.from d to (� ft. ❑Yes �No ❑Yes ❑No 0 Unknown <br /> 600 Twelve Oaks Center Dr in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> Ste 654 <br /> Wayzata, MN 55391 in.from to ft. 0 Yes ❑No 0 Yes 0 No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above Screen from '/C f to Q o f ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> p(Rods/Drop Pipe 0 Check Valve(s) 0 Debrisb0 Fill 0 No Obstruction <br /> Type of Obstructions(Describe) 3 f)/ /'"fr.4 o C"Nx ziU 9-e <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? f, es CI No Describe <br /> FORMATION T <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Type '--I Akin Pi)M 1' <br /> drift 0 80 (Removed ❑ Not Present 0 Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 'No Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal <br /> ]/�� in.from to ft. ❑ Perforated 0 Removed <br /> in.from to ft. 0 Perforated El Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material " ' "7 f J?Tom U' <br /> N4O to AO ft. yards Z bags <br /> from to ft. yards bags <br /> from • to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? 0 Yes lI o How many? <br /> 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 Stodola Well Drilling Co., Inc. 27172 <br /> Contractor Business Name License or Registration No. <br /> � ....110r.- 12-15-05 <br /> A-"onir.Representative Signat. - Date <br /> LOCAL COPY H <br /> 243236 Jim Antonson <br /> Name ofPerson Sealing Well or Boring <br />