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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2611701 <br /> SealWELL OR BORING LOCATION WELL AND BORING SEALING RECORD Minnesota Well No. <br /> County Name 'I <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> v ne n i+ (Leave dank R-1,10.1)) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 3 29 '' '/ -2-3 J ukt' 07 <br /> GPS Latitude degrees minutes seconds Depth Before Sealing 7 ft. Original Depth ft. <br /> LOCATION: Longitude_____. degrees minutes secondsUIFER(S) STATIC WATER LEVEL <br /> A <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 3800 Wayzata <br /> Blvd {, � W LL/BORING Measured ❑Estimated Date Measured <br /> �OIJI! �vti@ D i� Water-Supply Well ❑Monit.Well r <br /> Show exact location of well or boring Sketch map of well or b g n <br /> in section grid with"X.' location,showing p erty ❑Env.Bore Hole ❑Other / ft. below ❑above land surface <br /> N lines,roads,an ildgs\t CASINGTYPE(S) <br /> in <br /> Steel ❑Plastic ❑Tile. ❑Other <br /> -- -------------- <br /> WELLHEAD COMPLETION <br /> , T <br /> W E I y,� <br /> --I-___- _ _ ----_ Outside: ❑Well House At Grade Inside: ❑Basement Offset <br /> %Mile pitless Adapter/Unit Buried ❑Well Pit <br /> T ❑Buried <br /> ,pSyJp,. 1/�^ ❑Well Pit ❑Other <br /> �L _YD &A 166+40 MILT ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME Li CASING(S) <br /> M Wi Diameter f DepthIF Set in oversize hole? Annular space initially grouted? <br /> in.from ♦ <br /> Property owner's mailing address if different than well location address indicated above �� �� to / ft. ❑Yes No ❑Yes ❑No ❑Unknown <br /> Carl Bolander & Sons Company in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 251 Starkey St <br /> .St Paul 3, M 107 _in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if different than property owners address indicated above Screen from !3 to Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe [j Check Valve(s) ❑Debris E]Fill E]No <br /> Obstruction <br /> Type of Obstructions(Describe)_7-�//� /'/ %L <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ❑No Describe <br /> FORMATION — - ---- <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> Type <br /> Removed ❑Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑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) (One bag of cement=94 Ibs.,one bag of bentonite=50 lbs.) <br /> Grouting Materia/rvEg/ 0417!�Ur from to/I ft. yards-je-,2_ bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes Alo 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 <br /> is true to the best of my knowledge. <br /> Dan Stc&l a W11_ nf'i���j�-CDs a 1ac a �f�r <br /> Contractor Business Name 1 tcense or Registration No. <br /> ti epresentative Slghature Certified Rep.No. Date <br /> LOCAL COPY H 261701 <br /> Name of Person Sealing Well or Boring <br /> HE-01434-09 IC#140-0423 6/068 <br />