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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 6 7 2 3 <br /> WELL OR BORING LOCATION Sealing N0. <br /> CountyName WELL AND BORING SEALING RECORD <br /> Minnesota Unique No. <br /> �rr� Minnesota Statutes,Chapter 1031 or W-series No. <br /> Ax=%��p� (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed . <br /> � �27 L»J ZV ��i��t '/a i! <br /> Numerical Street Address or Fire Number and City of Well or Boring L.ocation � <br /> / /-� <br /> 2�77 ,�,)�d�I�Q� �� �c�r� 5�3� Depth Before Sealing ft. Original Depth �./ ft. <br /> Show exact location of well or boring Sketch map of well�r boring ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". , location, showing roperty ingle Aquifer ❑ Multiaquifer <br /> �� lines,roads,and bu d� s. ,�/ <br /> N ,��, �1 ELUBORING �easured ❑ Estimated <br /> � � � � �/dJater Supply Well ❑Monit.Well �� <br /> --�- -i-- --i-- --�-- � �„�,,,. . /\• . . <br /> }} ❑ Env.Bore Hole ❑Other ft. elow ❑above land surface <br /> 1 <br /> �y --�- -;-- --�-- --�-- E _ ;: CASING TYPE(S) <br /> � � � � <br /> � � � � ; <br /> --�- -�-- --�-- --�-- � � ' Steel ❑ Plastic ❑Tile ❑ Other <br /> 1 I � I '/.mile '� <br /> -�-- --�-- --�-- --�-- � � 't1 CASING <br /> `�� Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> �1 mile� �-`�� j� _� in.from.�_ to�ft. ❑Yes � �qp ❑ Yes ❑ No ❑ Unknown _ <br /> � 7 ' <br /> PROPERTY OWNER'S NAME _ in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> x <br /> Properry owner's mailing atldress if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> �Y V�S Drexe 1 A Y� SCREEWOPEN HOLE <br /> Edina MPi 55424 ' -l�'b ' <br /> / Screen from�to ft. Open Hole from to ft. <br /> O B ST R U CT I O N/D E B R I S/F I L L <br /> WELL OWNER'S NAME Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if different than properry owner's address indicatad above. Type of ObstruCtion/Debris/Fill ��,(�A1���1�� Q- ��� � <br /> Obstruction/Debris/Fill removed? es ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ot Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log irom nearby we�i or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE FIOLE: <br /> . No Annular Space Exits <br /> � � � <br /> Annular space grouted with tremie pipe <br /> :`� <br /> ;� ❑ Casing Perforation/Removal <br /> in:from_ to h. ❑ Pertorated ❑ Removed <br /> in.from to h, ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) � <br /> 4 '"'� f � <br /> Grouting Material �� to��}ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes o <br /> LICENSED OR REGISTERED CONTRACTOR CERTIF A N <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 /> o •! • License or Re � . <br /> � _..�_.._ ' � -.. <br /> . � _ -��r �\ �/l� � � <br /> i eseh ive Signaturef- Date ` <br /> _....!' ; <br /> I:.,. "'� <br /> _.i - - - -2�.s����..� �'v <br /> n ry � � Name of Person�Sealing Well or Boring <br /> LOCAL COPY H .E.. :.s � F � � <br /> HE-01434-02 10/95R <br />