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.::. ... . ...r.. �. ....,..�.... . .._. ...�.. .. ... .. .. , ... .K r...-. .,.::. ......... . .... . ... � .. . .r .. .. ,i,. .... . . ..__...�... <br /> WELL OR BOFING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Bonng + ��O^� <br /> �o���Y N�me — WELL AND BORING SEALING RECORD Sealing No H 1 L 1 � <br /> Minnesota Unique No � <br /> Minnesota Statutes.Chapter 1031 or W-series No. <br /> i <br /> Hennepin ILeave blank d not knownl � <br /> Township Name Township No. Range No. Section Na Fraction�sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Osono 117 23 OS 1�ODU�� /r.;1 . �;,: `�' 'j <br /> Numerical Street Address or Fire Number and Ciry ot Well or Bonng Location y <br /> i <br /> 34 5 I.eaf S t, ��On� Depth Before Sealing _J -� R Original Depth �', __ft <br /> Show exact locafion of well or boring Sketch map of well bonng A�UIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing roperty Single Aquiter ❑ Multiaquiter <br /> lines,roads,and bwl ings. <br /> N ___,_., WELUBORING �Measured ❑ Estimated <br /> � � ' ' j � �Water Supply Well ❑MoniL Well <br /> --�- -�----�-- —� � ! �% <br /> '�' ❑ Env.Bore�Hole ❑Other _ �f"'� ft. �below ❑ above land surface <br /> .__._.._. 1 <br /> W --�- - -- - -- --i-- E ' CASING TYPE(S) <br /> � � � <br /> � � � <br /> � � � . ........_......... -,. <br /> -�-- � ' • � -�f Steel ❑ Plastic ❑Tile �Other <br /> --- --r- --�-- � , > <br /> � I i mde � �.� <br /> -�-- �-- � 4 ti\ � '. CASING <br /> --- - --�— Y <br /> � �,__ Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> � { <br /> �r�r m;ia—� ` _ '�l in.from '� to .R�`� fl. ❑ Yes �"No ❑ �es ❑No ❑ unknown <br /> ��n�Y��E��nM�ompany in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Properry owner's mailing address if diKerent ihan well location address indicated above. in.from tp ft. ❑ Ye5 ❑No ❑ Yes ❑No ❑ Unknown <br /> 4i00 Berkahire Laae SCREEWOPENHOLE <br /> Ply�outh 5 5446 Screen from �" to l�') ft Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �'Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailin address if different than ro e owner's address indicated above. `" '� j <br /> 9 P P rtY Type of Obstructions(Describe) ��� •�"� i.% i i��� � <br /> 1 ! <br /> Obstructions removed? `�`Yes ❑ No Describe <br /> PUMP <br /> ; y'. <br /> TyPe �:,s <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> It no�known,indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ,_�J � `� � No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> s <br /> in.trom_ to n. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Ramoved <br /> Type of pertorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> i, <br /> Grouting Material '`'�` �-"`��'from to f } (t. yards '" ba s <br /> 9 <br /> from to ft. yards bags <br /> from to R. yards bags <br /> from to__ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEAUNG �r 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 with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best ot my knowledge. <br /> Don Stodola We12 Drilling co. , iNc. 27i72 <br /> Contracfor Business Name �.. License or Registrallon 170. <br /> , : /, „_ <br /> �' ; , <br /> r <br /> �� /'y!�,' .. -c. �-�, /��� �i � . ! <br /> . 'A onred Representative Signature Date <br /> � .. - . .,%�..i . -,t,i.l'!'`� tiw <br /> LOCALCOPY H <br /> 12 9 0 21 Name ol PersomSealing Well or Bonng <br /> HE-01434-03 2/97 R <br />