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wELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i �Q���� � <br /> ry WELL AND BORING SEALING RECORD M;��'ego a u��q�ewe��No. iCH_ p — � <br /> Coun Name <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin h.�.a.���,k�, <br /> Township Name Township No. Range No Secfion No. Fracuon�sm.�Iq.) Date Sealed Date Well or 8oring Constructed <br /> 4rano 117 23 17 2�3-�02 �- pC ,- <br /> Numencal Street Adtlress or Fiie Number and City of Well or Bonng Location <br /> 18�7 Fagexness P� Rd� �rQn� P 9 �� ' 9 P �� ' h <br /> De th BefOre Sealin � fl. Ori inal De th <br /> Show exact locatwn of N•ell or boring Sketnj�map ot well or bonnq AOUIFER(S) STATIC WATER LEVEL <br /> m section grid wi�h"X". �� �Iqg�bn, showing property y�9�Single Ayuder � Multiaquifer <br /> -, lipes,roads,and buildings <br /> ry ;' j `•.� WEWBORING Measured ❑ Eshmated <br /> , � � � � �, Water Supply Well ❑Monit.Well � <br /> � � "�_' '_i ` <br /> ` ❑ Em.Bore Hole ❑Olher _ _�R. [�below ❑ above land surtace <br /> W —�- -i-- -i-- --i— E .� CASING TYPE(S) <br /> � � � � <br /> � � <br /> � � � � / <br /> ` --�- -�- -i-- --i-- C t <br /> , y Steel � Plastic �Tile �Other <br /> � � � � �� ,. , . <br /> _ -�-- -�-- -�-- --�— � �/ i 1� CASING(S) <br /> �Z~ Diameter� Depth � Set in oversize hole? Annular space initially grouted? <br /> LL�� S <br /> �(�—r mire� � � t/ in.from � to ��� tt. ❑ Yes �lo ❑ Yes ❑No ❑ Unknown <br /> I i T� <br /> PROPERTY OWNER'S NAME , m.from to R. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> Property ownei s ailing addres f different t�an wel ocation a ress indicatad above. in.trom to R. ❑ Ye5 ❑No ❑ �es ❑No ❑ Unknown <br /> 7�2�"t71-0490 SCREEWOPENNOLE � <br /> � � <br /> Screen from ��� to ��S%� ft. Open Hole from to R. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owners mailing eddress if ditterent than properry owner'S address inAlcated above. Type Ot ObSt�uCtionS(DescribB) �111/tJrG`� / S-�� Q'" ��Jm/ <br /> Obstruclions removed? �1'es ❑ No Describe <br /> PUMP <br /> TY� �c4� i%�rn f�' <br /> OEOLOl31CAL MATERIAL COLOFt MARDNESS OF FROM TO Removed ❑ Not Present ❑ Othe� <br /> FORMATION <br /> N rat krawn,indicate estimated formatbn log trom nearby weli or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING ANO BORE HOLE: <br /> � - k �(Jo Annular Space F�cists <br /> r`` �,a � ''� <br /> ❑Annular space grouted with tremie pipe <br /> ,�, ❑Casing Perforation/Removal <br /> in.from to k. ❑ Pertorated ❑ Removed <br /> in.irom to R. ❑ PeAorated ❑ Removed <br /> Type of peRora[or <br /> ❑ Omer <br /> GROUTiNG MATERIAL(S) (One bag of cement=841bs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material 3N�� '���"fr6m � to� tt. yarAs f[_ bags <br /> trom to ft. yards bags <br /> trom to R. yards begs <br /> from to__ R. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The information contained in Mis repoR is <br /> true to the best of my knowledge. <br /> Don Stodols Well Drf2ling Co. , inc. 27172 <br /> Confrador Business Name � _ Licerrse a Regisfreh'on Cio. <br /> �, - . <br /> __ - ,� � �fr� ,�� ..� i <br /> o�ed resentetive Signafure' Date <br /> �.� _ _ � �.i�. ./,iJS'`!�_ <br /> ���A�.���v H 18 5 9 3 0 Name o/Person Sealing Wel/br 9ori� <br />