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,<- _ ,�- ,��'�� <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring .t �b��� � <br /> Y7�`lL OA B�RING LOCATION I <br /> WELL AND BORING SEALING RECORD sea�i�9 No. �H j p <br /> co�r,ry Name Minnesota Unique Well No. ----- ---- --� <br /> ���Qep�,(Z Minnesota Statu�es, Chapfer 1031 or W-series No. <br /> (Leeve tlarik tt iwt krawn) �.__'_.__._ __ � <br /> Township Name Township No Fange No. Section No. Frachorr.lsm.i Ig.) Date Sealed Date Well or Bonng Consiructetl <br /> orono �17 a3 Io . ,. <br /> Numerical Sireet Adtlress or Fire Number and Ciry ot Well or Bonng Location-� � �� <br /> 1955 Shotelint �C y flroflo Depih BeforP Sealing__ �„�� R Original Depth � h <br /> Show exact location of well or bormg Sketch map ot well o�bonng (10UIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". locahon, sho�roperty P�Single Aywfer � Mulnaquder <br /> �`.� II�'s,roads, d b ildings. <br /> N ,_„��, ��..� WELUBORING Measured ❑ Estimated <br /> I , , � Water Supply Well ❑Monit.Well — <br /> - - - -- -i-- — -- � <br /> ❑ Em.Bore Hole ❑Other �' �__ft. `�below ❑ above land suAace <br /> /� <br /> � -�- -�-- -;— --;-- CASING TVPE�S) <br /> W E <br /> � � � � <br /> � <br /> �, -�- -�-- -i-- --�-- � Steel � Plas[ic �Tile �Other <br /> � � � � <br /> .. �i�e ��\ CASING(S) <br /> -'-- -i-- -�-- --�— <br /> l3� Diamete� �� Depth � Set In oversize hole? Annular space initially grouted7 <br /> S � /��'T <br /> �—i m�re—#�'r ��in from� to_��l_J n. ❑ Ves ❑No ❑ �es ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ �es ❑ No ❑ Unknown <br /> Pr � aiG s i tion address indlcated above. in.irom to ft. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> 530 Shorevf.e� Park �C� screen from ro ft Open Ho�e trom_t__/_L�o�� n. <br /> Shorevie�, Mht 551�b <br /> AtCn:�igflCB (`,tf !3 oesTaucnoNs <br /> WEIL OWNER'S NAME Rods/Dro Pi e <br /> p p ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing adOress il tliflerent ihan properry owner's aAdress indicated above. Typ6 of Obstruc�ions(Describe) a����L'� /'".���f�� <br /> Obstructions removed? Yes ❑ No Describe <br /> PUMP <br /> Type �1 1��1rS ��'.l�p <br /> 6EOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not Wawn,indicate estimeted tormatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ' � `� ,f o Annular Space bcists <br /> '�� ❑Annular space grouted with tremie pipe <br /> p� �y, � ❑CasingPerforation/Removal <br /> in.from to R. ❑ PeAorated ❑ fiemoved <br /> in.from �p tt. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ otner <br /> GROUTING MATERIAI(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> �/�/+' /� Q(� t <br /> Grouting Matenal���F��"'T�Sm _.3,rC— to�._/_Q tt. yards �� bags <br /> . from to R. yards bags <br /> from to ft. yards bags <br /> from to__ it. 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 /> UCENSED OR REGISTEREO CONTRACTOR CERTIFICATION `{ <br /> tr�is well or bor�ng wa;szaled:�,ccordznos+virn,?,�innes�ta Rules,Chapte•4725. The informatio�contained in this report is <br /> � t�ae to the bost of my knowladge- <br /> Doa Stocla2a �1e11 Dri113ng Co., Iac.__27172 <br /> --------_ --- <br /> Contracror Business%Yam� -�... License or Registre0on I�o. <br /> �� J- � �/ <br /> . . A nz presen afive igna-s� �Date . . <br /> ` �+r.l��� `✓"'^'~�� <br /> LOCAL COPY u 1 ������� Name of Pe eling Well or Bonng <br /> ri j <br /> t� <br />