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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 385563 <br />County Name WELL AND BORING SEALING RECORD MinnesoSealing ta Unique Well No. <br />Minnesota Statutes, chapter 1031 No <br />or Wus erie kr—) <br />Township Name Township No.flange No. Section No. Fraction (sm. -+ Ig.) Date Sealed ) Dale Well or Boring Constructed <br />S <br />GPS LOCATION -decimal degrees (to tour decimal places) +y <br />Depth at Time of Sealing ! l ft. Original Depth—ft. <br />Latitude Longitude <br />NUIFER(S) STATIC WATER LEVEL <br />Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑ Multiaquifer <br />32.47 G a 5 c o Uri, U r o o o J�) 3 6 4 WELL/BORING Measured Date Measured ❑ Estimated <br />X Water -Supply Well E) Env. Well <br />Show exact location of well or boring Sketch map of well or boring <br />r. <br />in section grid with "X" location, showing property / ❑ Temp. Boring ❑ Other ft. ['below ❑ above land surface <br />lines, roads, and buildings:° <br />N f CASINGTYPE(S) <br />'[Steel ❑ Plastic ❑ Tile ❑ Other' <br />i h f r ' WELLHEAD COMPLETION <br />W t E T Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: -r Basement Offset <br />f <br />'b Mile Well Pit El Buried Ll <br />[:)'Well <br />yWell House <br />' <br />„ <br />1 ❑ <br />' -1-711 s I Other ,_I - <br />—1 Mile - ❑ Buried <br />❑ Other <br />For temporary borings, provide additional locati n CASING(S) <br />information, a site sketch, and geology on a se rate page. Dia ter Depth Set in oversize hole? Annular space initially grouted? <br />PROPERTY OWNER'S NAME/COMPANY NAME in. from to IWft. ❑ Yes ❑ No ❑ Yes ❑ No Yunknown <br />d LLC <br />Property owner's mailing address If different than well location address Indicated above in. from to ft. ❑ Yes ❑ No Yes ❑ No ❑ Unknown <br />153 1� Lake St in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />Wayzata, k1h 55304 SCREEWOPEN HOLE <br />fj �J <br />WELL OWNER'S NAME/COMPANY NAME Screen from i« / t. -L7 -/-ft. Open Hole from to <br />OBSTRUCTIONS <br />Well owner's mailing address if different than property owner's address indicated above Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />Type of Obstructions (Describe) <br />Obstructions removed? YYes ❑ No Describe <br />PUMP <br />GEOLOGICAL MATERIAL COLOR HARDNESSORFROM TO Not Present Present, Removed Prior to Sealing ❑ Other <br />FORMATION ❑ <br />If not nown, indicate estimated formation log from nearby well or boring. Type A f <br />4 I METHOD USED T DEAL ANNULAR SPACE BE EEN 2 CASINGS, OR CASING AND BORE HOLE <br />5(No Annular Space Exists ❑ Annular Space Grouted with Tremle 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 WNo TN# <br />GROUTING MATERIAL S) --��-- s <br />Grouting Material I/�° f frt3m to ft. yards w 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 XNo How many? <br />LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The information contained in this report <br />is true to the best of my knowledge. <br />von Stodola well Drilling Co., Inc. lbyl <br />Licensee Business Name License or Registration No. <br />° <br />todriM frep e entatrbe Signature —� Certified Rep. No. Date <br />LOCAL COPY H J 8 5 5 63 <br />Name of Person Sealing Well or Bq rag <br />HE -01434-17 ID# 53159 '�, 11/19R <br />