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WELL OR BORING LOCATION MINNESOTq DEPARTMENT OF HEALTH Minnesota Well and Boring H 30 2 8 4 9 County Name WELL AND $ORING SEALING RECORD M�,a�','e90 a°u��q�e we��No. - --- Minnesota Statutes, Cha ter 1031 or W-series No. P ILeave blank it no�known) Township Name Township No. Range No. Section No. Fraction(sm.-a Ig.) Date Sealed Date Well or Boring Constructed , � /5� A / Y ^��, r GPS Latitude degrees minutes seconds Depth Before Sealing G�.�.J ft. Original Depth ft. LOCATION: Longitude.__._ degrees minutes___ secands AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location - ingle Aquifer '�.Multiaquifer fC ,,,) 2476 . Ave vLV[ly �✓ELL/BORING �vleasured ❑Estimated Date Measured S�i/Y/C D�/ �Water-Supply Well ❑Monit.Well , Show exact location of well or boring Sketch map of well or boring �� Env.Bore Hole '`Other __��_fL �below ❑above land surface in section grid with X." location,showing property N t lines,roads,and buildings. CASING TYPE(S) ...;� --'-----'--- --`-- ---'-- �/ � � � �/�6teel ❑Plastic [ ;Tile J Other _____ _ � -''---'"'""'""`` ---�-- .�� :�{� WELLHEAD COMPLETION �` W � : ; : ET , ' ' _;__ __�__ Outside: ❑Well House ❑At Grade Inside: �asement Offset : ° --�-----�-- - � E , , , ; 'h Miie tl A /U t ❑Buried �Well Pit � , , , , � ❑Pi ess dapter ni � � � � --'�-----�-'----�-- '--•-- �� ❑Buried S ❑Well Pit �i Miie--{ ❑Other ❑�ther PROPERTY OWNER'S NAME/COMPA AME CASING(S) Diameter M Depth � Set in oversize hole? Annularspace initially grouted? Property owne mailing address if diflerent than well location address indicated above �� �_in.Gom� ta__�'�ft. LJ Yes �No ❑Yes �]No ❑Unknown 250� nunwoody Ave O�, �T 5�� . in.irom to _fL ❑Yes I_j No ❑Yes ❑No ❑Unknown l 11'1 1 ;� � __in from to ft. [j Yes L�No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE . 'y�,� Well owner's mailing address if ditterent than property owner's address indicated above Screen from��to_�W ft. Open Hole from to_ ft. ' OBSTRUCTIONS �Rods/Drop Pipe [�Check Valve(s) L�]Debris ❑Fill [��No Obshuction Type of Obstructions(Describe),�.�//�/�� /1f'r= �" �� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ,�Yes _J No Describe FORMATION If not kn wn,indicate estimated formation log from nearby well or boring. PUMP ' TYPe "�` ( P�mn f�-�` �Removed _]Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No 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 REC IVED ❑Other GROUTING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite=50 Ibs.) ♦� �►/ /�.�`'1 �ys.r. �-�� . Grouting Material l�+L'ft� t'`��from� to�_�,,r�. yards GJ bags C'� 1 � 4RON from to ft. yards_ bags from _ to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �I Yes No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true ta the best of my knowledge. T�on 5todola We11 Drillirt� Co., Inc. 1691 Licensee Business Name � License or Registration No. _._ .m - � � .,> - /.:i- /�, i pr en tive Si re Certified Rep.No. Date �� LOCAL COPY H 8�A} � 1-'v'�' `��`�Y''�-JSY�.--' ��. 3 O� �" "� Name of Person Sealing Well or Bor g: HE-01434-12 IC#140-0423 �� 9/09R