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WELL OR BORING LOCATION Minnesota Well and Boring H 5 502? <br /> MINNESOTA DEPARTMENT OF HEALTH Sealing No. <br /> County NameWELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Hennepin Minnesota Statutes.Chapter 1031 or W-series No. l� <br /> (Leave blank it not known) <br /> Township Name Township No. Range� No. Section No. Fraction(sm. •Ig.) Dale Sealed Approximate Date Well <br /> Orono 117 23 08 4 -00,Q5 Ir4 7.1-(...),,,...1r !� or Boring Constructed <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <� �S/ / <br /> 3430 Northshore Drive Ori, Mn. Depth Before Sealing / 0 ft. Original Depth -. /C/� ft. <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level XAccurate <br /> in section grid with'X". - --• lines. <br /> roads.and• ildings. ❑Approximate <br /> N <br /> 4/0 i • <br /> i lieSingle Aquifer CI ^Multiaquifer ft. below above land surface <br /> - 1 - CASING TYPE <br /> W ' E L'_ <br /> T >teel ❑Plastic ❑Tile 0 Other <br /> I 1 v mile <br /> Screen from -- `•3 ? to 70 / <br /> ft. Open Hole from to B. <br /> 1.0.---/mile—►I /vii.I(-i t', l',.a( r • OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME Ig/Obstruction ❑Debris ❑Fill <br /> Water & Asscseiates, Inc. ' _ '`.._ <br /> Type of debris/obstruction .I41,1�`r PLP) 9 ✓E <br /> Mailing Address if different than property address indicated above. <br /> 10340 Viking Drive Obstruction/Debris/Fill removed? %Yes 0 No <br /> S. 110 PUMP <br /> Eden Prairie, Mn. 55344 U<_i Foley <br /> Removed 0 Not Present 0 Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> drift 0 /� i <br /> y 4n I in.from v to /3+L..1 ft. ❑Yes $No ❑Yes CI No ❑Unknown <br /> i V in.from to ft. 0 Yes 0 No ❑Yes ❑No 0 Unknown <br /> in.from to ft. 0 Yes ❑No 0 Yes 0 No 0 Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> Ylo Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to _ ft. ❑Perforated ❑Removed <br /> - - -- Type of perforator <br /> r —..-1 <br /> ❑Other <br /> GROUTING MATERIAL <br /> / <br /> Grouting material/_W.'" C'0?w/ from to /9/U ft. yards 3 bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATADIFFICU,LTIt IN$ <br /> (OCTC1 y,git <br /> from to ft. _ yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? 0 Yes No <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 is <br /> true to the best of my knowledge. <br /> DONT S'I'O XLA WELL DRILLING CO., INC. 27172 <br /> Contractor Business Name License or Registration No. <br /> i <br /> ///�y�/ � -- .74 6x-30-94 <br /> uzi ed Representative Signature Date <br /> I.L:CAL COPY H 55022JimAntonsan <br /> Name of Person Sealing Well or Boring <br /> HF_n1n•Id_n1 <br />