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HE -01434-16 ID# 53159 9/17R <br />MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br />SealWELL AND BORING SEALING RECORD Minnesota aoUnique Well No. <br />Minnesota Statutes, Chapter 1031 or W—sseries No. <br />i 0 i 1 (` <br />H 370056 ( lJ �) <br />WELLORBORINGLOCATION <br />Name <br />T <br />Township Name <br />Township No. <br />Range No. <br />Section No. <br />Fraction (sm. —r Ig.) <br />Date Sealed <br />Date Well or Boring Constructed <br />Ornn <br />117 <br />23 107k <br />b E' <br />GPS LOCATION — decimal degrees (to four decimal places) <br />Latitude Longitude <br />Depth at Time of Sealing�_ft. <br />Original Depth ft. <br />AQUIFER(S) <br />Single Aquifer ❑ Multiaquifer <br />STATIC WATER LEVEL <br />/� <br />Measured Date Measured 5MI bA El Estimated <br />f <br />ft-)Cbelow ❑ above land surface <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />r� <br />Q Park DC O ow <br />ELL/BORING <br />Water -Supply Well ❑ Env. Well <br />❑Temp. Env. Well ❑Other <br />Show exact location of well or boring Sketch map of well or boring <br />in section grid with "X" linesn, showing property <br />N , roads, and bu.'dings' <br />CASING TYPES) <br />Steel ❑ Plastic ❑ Tile ❑ Other <br />___ __a__ ----------- 4__ <br />W E @ ' <br />__ ___r__ T <br />'h Mile <br />r 1 <br />s <br />WELLHEAD COMPLETION <br />Outside:�PitI ess Adapter/Unit ❑ At Grade Inside: El Basement Offset <br />❑ Well Pit ❑ Buried ❑ Well House <br />Other ❑Well Pit <br />❑ Buried <br />�1 Mile <br />For multiple temporary environmental well , proro'vl"de ad 1 lona I ca loris � <br />information, a site sketch, and geology on a separate page. <br />❑ Other <br />CASING(S) <br />Diamelel f _e if Depth / Set in oversizte hale? Annular space initially grouted? <br />�— in. from_�� tot ft. ❑ Yes ][I No ❑ Yes ❑ No ❑ Unknown <br />in. from to ft. ❑ Yes /�❑ No ❑ Yes ❑ No ❑ Unknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Norton Rmes <br />Property owner's mailing address if different thanwell location address indicated above <br />1._8215 455th Ave N. /•.Iia D <br />Plymouth, M 55446 <br />WELL OWNER'S NAME/COMPANY NAME <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />SCREEWOPEN HOLE <br />I <br />Screen from to� ft. Open Hole from to I. <br />OBSTRUCTIONS <br />Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />Well owner's mailing address if different than property owner's address indicated above <br />Type of Obstructions (Describejl 11J41,4 02&09� ¢ A~ <br />Obstructions removed? X Yes ❑ No Describe <br />PUMP <br />❑ Not Present Present, Removed Prior to Sealing ❑ Other <br />Type <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TO <br />If not Known, indicate estimated formation log from nearby well or boring. <br />" <br />METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />No Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal <br />Casing Diameter <br />in. from to ft. ❑ Perforated ❑ Removed <br />in. from to ft. ❑ Perforated ❑ Removed <br />Type of Perforator <br />VARIANCE <br />Was a variance granted from the MDH for this well? ❑ Yes yNo TN# <br />GROUTING MATERIAL(S) (One bag of cement = lbs., one bag of bentonite = 50 lbs.) <br />Grouting Material AC��t from Q / to�-0 `ft. yards_ R bags <br />from to ft. yards bags <br />from to ft. yards bags <br />OTHER WELLS AND BORINGS <br />Other unsealed and unused well or boring on property? ❑ Yes ANo 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 <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />is true to the best of my knowledge. <br />Don Stodola Wa11 Drilling Co,. Iw.- 16% <br />Licensee Business Name License or Registration No. <br />d e A t a Signature Certified Rep. No. Date <br />1 <br />LOCAL COPY <br />H 7 <br />�.` �J V <br />Name of Person Sealing Well or Darin <br />HE -01434-16 ID# 53159 9/17R <br />