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wELL OR BORING LOCATiON MINNESOTA DEPARTMENT OF HFALTH M�nnesota Well and Bor�ng H ������ <br /> WELL AND BORING SEALING RECORD Minne oNa Unique No. <br /> County Name — — - <br /> Mmnesota Statutes,Chapfer 7031 or W-senes No � <br /> i�ennepin ILeave biank d not known� <br /> �� Township Name Township No. Range No. Section No. Frection(sm.-►IgJ Date Sealed Date Well or Bonng Consiructed <br /> Orono 317 23 OS 33-�0(}� 7 ,.lU�� C�� <br /> Numerical Street Address or Fire Number and Gry of Well or Boring Location /�O � //h � <br /> �510 B�ys ide Ad� �r�n0 Depth Before Sealing n Onginal Depth L� n <br /> Show exact Ixahon of N-ell oi boring SketchJnap of well or bonng q01lIFER(S) STATIC WATER LEVEL <br /> in section grid with'X'. bc�uon, howing property Ji Smgle Aywfer ❑ MultlaquAe� <br /> lines,roads, nd buildings. <br /> ; N WELL/BORING (�Measured ❑ Estimated <br /> ,,a ,�\ �Water Supply Well ❑Monit Well � � <br /> - '� `�� ❑ Env.Bore Hole ❑Other _ � ft. �low ❑above land surface <br /> � � � � �' i' � <br /> W —i-- -i-- -i-- --i-- E , CASING TVPE(S) <br /> � � � � <br /> \ <br /> —�- ---- -�-- --�- � �, �'� �,teel ❑ Plastic ❑Tile ❑Other <br /> s mee <br /> : �-'� � <br /> � CASING <br /> --�- -�-- -�-- --i— ' ' <br /> `� Diametgr f /r Depth � Set in oversize hole7 Annualar space iNtially grouted? <br /> ` i <br /> ��m;�� \ �� in.irom �� to /� fl. ❑ Yes �(No ❑ Yes ❑No ❑ Unknown <br /> t � ♦ <br /> PROP RTY OWNEA'S NAME in.trom to tt. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Ro�bert Crai �bi?1P.3 <br /> Proparty owner's mailing address If tlilferent than well loca6on address Intlicated above. in.from to tt. ❑ Ves ❑ No ❑ �es ❑No ❑ UnknOwn <br /> 2ZQ�� B��C�EtS R� SCREEWOPENMOLE y <br /> ithorewood RiN 55332 1C1 //d � <br /> � Screen irom to R. Open Hole irom to fl. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris Fill ❑ No Obstru�n <br /> .1�R/�/' L�/�< 4� .1 Y i'.. <br /> Well ownefs meiling aAOress it diflerent Man properry owner's aadress indicatetl above. Type Of ObstruClions(DOSC�ibe) f <br /> Obstructions removed? �Yes ❑ No Describe <br /> PUMP <br /> h <br /> 7y� If- / �l✓Yl� <br /> OEOL061CAL MATERIAL COLOR HARONESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> FORMATION �7MOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> If rat krawn,indicate estimated tormatbn log trom nearby well or bonng. �� <br /> J�,No Annular Space Exists <br /> ,i � � ❑ Annular space grouted with tremie pipe <br /> � ❑ Casing PerforatioNRemoval <br /> in.from to R. ❑ Pertoreted ❑ Removed <br /> in.from �o ry. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> 1Uc�'1' �i- y ,�7� ��/�� � <br /> Grouting Material �T��-a� .� to 1 f r� h. yards � begs <br /> irom to fl. yards baga <br /> from to ft. yards begs <br /> from to__ ft. yards bags <br /> REYARKS,SOURCE OF DATA,dFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes �Jo How many? <br /> LICENSED OR HEGISTERED CONTRACTOR CEFiTIFICATION <br /> This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The infortnation conteined in this repat is <br /> true to�he best of my knowledge. <br /> dan SCor3ala�ieli Drillin� Co. , Inc. 27172 <br /> Contrecfor Business Na �-� License a Regishation fvo. <br /> .+` <br /> ���� � � � <br /> s. .� -.fda - .- � � ^���.. f. � .. <br /> Authon ��Re resentative Signature-�' � Dete � <br /> . <br /> -..r` <br /> , . . ' '� . :'� :- �� ' �e�. <br /> "' Neme o/Person Sealing Well or Bonng <br /> �ocucoPv H <br /> HE-01434-04 $�98 R <br />