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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 108172 <br /> WELL OR BORING LOCATION Sealing No. <br /> County Name Hennepin WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. ange No. Section No. Fraction(sm.i Ig.) Date Sealed Date Well or Boring Constructed <br /> R <br /> 03:uno 117 2 s L5 1 4-49UUS 7 / -•:r <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 46 TbnkaWa. 12cod OT0110, Mn.. 5'-1 56 Depth Before Sealing ;;o.(S ft. Original Depth <br /> Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property Single Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. <br /> N WELUBORING El Measured Estimated <br /> , j�l \\ Water Supply WeII ElMonit.Well <br /> /r <br /> .,------- ❑ Env.Bore Hole ❑Otherf�_ft. [below ❑ above land surface <br /> W E CASING TYPE(S) <br /> ---- -�-- <br /> ----- -- �teel ❑ Plastic ❑Tile ❑ Other <br /> mile <br /> -- -�-- -- -- -- -- I CASING <br /> Diameter Depth � r Set in oversize hole? Annualar space initially grouted? <br /> I <br /> mile in.from to�5�� ft. ❑ Yes [Xlo ❑Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> Ed Ca1we11 <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> 471--1946 SCREEN/OPEN HOLE <br /> r i <br /> Screen from -7(,—, to—_ ft. Open Hole from to ft. <br /> O B S T R U CTI O N/DEBRIS/F I L L <br /> WELL OWNER'S NAME ❑ Obstruction [] Debris ❑ Fill Xo Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill <br /> Obstruction/Debris/Fill removed? ❑ Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO El Removed ^ot Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ❑ No Annular Space Exits <br /> 1• ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material /^/i1/K A-ft�m �_ 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 CERTIFICA ION <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 /> Contractor Business Name License or Registration No. <br /> ?0K�0-dF&Presentfitiite signature Date <br /> Name of Person seal n�g Well or Boring <br /> LOCAL COPY H 1- 08172 . <br /> HE-01434-02 10/95R <br />