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, ��.�_ _ _ <br /> �� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 0 5 6 8 3 <br /> County Name <br /> WELL AND BORING SEALING RECORD MennfesoNa Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> ,f.� (�eave blank it nol knownJ <br /> �Towns ip ame ownship No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> �` <br /> � GPS Latitude degrees minutes seconds � � :. <br /> LOCATION: <br /> Depth Before Sealing ft. Original Depth � ft. �� <br /> Longitude degrees minutes seconds ppUIFER(S) S7ATIC WATER LEVEL <br /> � Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑MWtiaquifer <br /> 2(7�0 Pheasant R.d Or�Ll� 55331 WELUBORING �Nleasured ❑Estimated <br /> �ater Supply Well ❑MoniL Well � / <br /> �� Show exact location of well or boring Skelch map of well or boring '/ <br />� in section grid with"X" location,showing property ❑ Env.Bore Hole ❑Other �' ft. f7�below ❑above land surface <br /> r� <br /> N ads,and buildings. CASING TYPE(S) <br /> �A. <br /> s Steel ❑Plastic ❑Tile ❑Other <br /> � <br /> W —�- - -- - -- -- -- E � p�� WELLHEAD COMPL.ETION <br /> .. , i ; ; la/ `C <br /> � � � � � � Outside: ❑Well House Inside: ❑Basement Offset <br /> --- �-- -;- --�-- �1 { <br /> �: 1 �+^"� � ❑ PitessAdaptedUnit �Mlell Pit � <br /> , -�-- -;-- -�-- --�-- I ts �` <br /> S � ❑Well Pit ❑Buried <br /> S <br /> . �r.--7 mM� <br /> � ❑Buried <br /> PROPE TY OLW+N2ER'S NyAME/COMPANY NAME CASING(S) <br /> B0� P 1 t C tl Co n s t ruc t i on Diam t�r� Depth � � Set in oversize hole? Annular space initially grouted? <br /> Property owner's•mailing address if different ffian well location address indicated above <br /> � in.frOm� to ft. ❑Yes [�lo ❑Yes ❑No ❑Unknawn <br /> 11725 54th Ave N <br /> Plymouth, MN S 5442 in.from to ft. ❑Yes ❑NQ ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE f <br /> Well owner's mailing address if diflerent than properly owner's address indicated above Screen from �� .t0�ft. Open Hole from 10 1t. <br /> OBSTRUCTIONS <br /> �ods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) �/UI�I�� �r/-^� ¢" �Ur`//'" <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 2S ❑ NO DOSCIIb2 <br /> FORMATION <br /> If not known,indicate estimated formation lop from nearby well or boring PUMP <br /> �` Type �� i U m � <br /> « �Removed ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> Li�vo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> /! <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one ba/g o��f bentonite=50 Ibs.) /'� <br /> Grouting Material���1� �-�_��/����frnm ✓ to S„15.1 K./ yards �L bags <br /> trom to tt. 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 borin on ro e � � <br /> g p p rty. ❑ Yes o How many. <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFLCATION <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 /> i <br />� Don Stodala Well Drillin,� Co„ Inc. 27172 <br /> Contracfor 8 sine s Name License or Registration No. <br /> � -�- � �/ C'r� <br /> z epresentative Signatwe Date <br /> \�:�,y,y� t�.��,�,.� <br /> LOCAL COPY H 'n� ,�,�Q� <br /> Name o/Person Sealing Well or Boring <br />