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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3��6 � 2 Counry Name WELL AND BORING SEALING RECORD Minnle90 a�Unique Well No. � Minnesota Statutes, Cha ter 1031 or W-series No. T�enne��i n p ��ea�e b�a�k,�o,k�ow�� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed (�rono 1.17 2 3 ?.1 '� '?�T �t.; !-�5- � ' GPS Latitude _ degrees minutes seconds Depth Before Sealing_tr�� fL Original Depth __ft. LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL Numerical SVeet Address or Fire Number and Ciry of Well or Boring Location �Single Aquifer ❑Multiaquifer ,�-t �_��.^) ? 27p� ct,Qc��nt �{.t� nC,Q{� ELLBORING 13 Measured []Estimated Date Measured L? �]Water-Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or boring ;-'�,Env.Bore Hole �Other � ft. in section grid with"X:' iocation,showing property -- I� � Q1]below �_j above land surface �^�s,roads,agd buildings. ' N � � �A CASING TYPE(S) ' --'--- I I I � � -'-- ---`-----`- c �'�� -'-- --'--- ---`-- ---t-- ELLHEAD COMPLETION Ile th ___ __ � S �'P ;]T [O er ' W , , � � ET �� W �,; __;___ __;__ _;____;__ I ,� Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset 'h Miie �Pitless Adapter/Unit ❑Buried ❑Well Pit - --'' ' - -- ❑Buried ' ' ' ' ❑Well Pit S � L ❑Other �1 Mile� �t'`-:"+..r�.,_..:�:...1� � .� ❑Other , PF[.OPERTY O-�W.^NwER,�'S NTATME�/COMPANY NAME CASING(S) �' ,7t��eW�J�1 Ld..lL. Diameter Depth Set in oversize hole? Annular space initially grouted? e " Property owner's mailing address if diflerent than well location address indicated above �_in.from� t0_ f 7�ft. ❑Yes �No ❑Yes ❑No �J Unknown 7�1J7 �a��$ta B�� in from__ to ft. ❑Yes ❑No ❑Yes ❑No j]Unknown St Lauis Park, MN 55�26 — in.from_ _ to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE Well owner's mailing address if ditterent than property owner's address indicated above Screen hom__� {� . to�� R. Open Hole from to ft. OBSTRUCTIONS ��Rods/Drop Pipe U Check Valve(s) �!Debris ❑Fill ❑No Obsiruction Type of Obstructions(Describe) f ' `� % 'F C� ..�+1��'J �(✓S� Q'� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. YPe �'V� r'i�.G�u�i ��Y f'�' r-, �� Removed ❑Not Present ❑Other _ �' METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �j No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Pertorated U Removed in.from ________to_ ft. ❑Perforated ❑Removed Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) 6 ,,� Z � �?; Grouting Material�li C T" ✓� from t.' to .L ft. yards bags 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? ❑Yes [�"No How many? i 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 to the best of my knowledge. 1km Stodola tdeii nrillint; Co,. inc. 1�i�11 + Licensee Bu�ess,/Oame � ..� � " License or Registration No. /'j'�l � � '✓ / `-�' � /'ti..� Ce,ie �,epresentative Signature Certified Rep.No. Date H C` ° /, �.,:�t•� .-..� LOCAL COPY 3� J� �L... Name of Person Sealing We/l or Boring HE-01434-13 IC#140-0423 5n2R