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i� ; <br /> WELL OR BOFiNG LOCA710N ' «. IUINNESOTA DEPY�,RTMENT OF HFALTH Minnesota Well and Boring ��^�^ ■ � <br /> �o���Y Name WELL AND BORING SEALING RECORD Sealing No H � �4 <br /> Hennepin Mmnesota Unique No. .; <br /> Minnesota Statutes,Chapter 1031 or W-series No. �+ <br /> (Leave blank A not known) '/ � t� <br /> Township Name Township No. Range No. Sec6on No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Construded <br /> G�ronc, 1 17 2`s 17 , . � — � <br /> Nyumerical Street Adtlress or Fire Number and City of Well or Boring Location (�'{ � / <br /> �1 f'i�J Bohn' s ��. R�. Urano, Mn. �.�p��tKBAtore Sealing g / fl. Original Depth ��_ft. <br /> Show exact location of v.�ell or boring Sketch map of well bonng AO IFER�S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing ropeny Single Aquifer � Multiaquifer <br /> Gnes,roads,and bw ings. <br /> N WELUBORING Measured ❑ Estimated <br /> � � � <br /> Water Supply Well ❑Monit.Well �. <br /> � � � � <br /> __r_ _r_ _'�" "�" } a./ �',./ <br /> �' ,- ❑ Ern.Bore Hole ❑Other _ � ft. �below ❑ above land surtace <br /> � •'��� ���. <br /> I ' I I �` � <br /> —�- -;-- -,— --,-- ,. <br /> W E , CASING TYPE�S) <br /> � � � � � <br /> � � � � <br /> � � 'i. <br /> —I-- -�-- -i-- —i-- � �, Steel ❑ Plastic ❑Tile ❑ Other - <br /> I I I I �i.m�le 4 '� <br /> —�- -i-- -�-- --�— � :.�.i f� �' CASING <br /> Diamet r �i Depth � Set in oversize hole? qnnualar space initially grouted? <br /> 1 S I �2 <br /> �r miie� �in.from� to S.LZ ft. ❑ Yes �No ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> Si�onehen e Gcan�t�r. . , <br /> Properry owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> 1 U91(} Wayzata $��7C�, SCREEWOPENHOLE � � <br /> Mtka. Mn.�`_�:�CS Q`� <br /> � Screen from�to�-� L ft. Open Hole from to ri. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME '�Rods/Dro Pi e <br /> p p ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if diHerent than property owners address indirated above. TypB ot Obst�uclions(DesC�ibB) ��11�!�� �l"r ¢ ��/'�/ <br /> Obstructions removed?�Yes ❑ No Describe <br /> PUMP <br /> TyPe �� �U��. <br />� HARDNESS OF Removed ❑ Not Present ❑ Other <br /> GEOLOGICAL MATERIAL COLOR FORMATION FROM TO <br /> It not known,indicate estimated formation log irom nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> i , �j No Annular Space Exits <br /> t . B t <br /> ❑ Annular space grouted with tremie pipe <br /> (,� ❑ Casing Perforation/Removal <br /> in.from �o ri. ❑ Perforated ❑ Removed <br /> in.from to h, ❑ Perforated ❑ Removed <br /> n <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> ��L � �? � //'� <br /> Grouting Matenal��7.r-�/ ���'�"��from � to�;.L ft. yards � bags <br /> from to fl. yards bags <br /> from to fl. yards bags <br /> from to__ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTEREO 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 /> DGN S`i'C�DGLI; WELL DRILLII�IG CC?. , INC. 2137:: <br /> Contractor Business Name License or Regisbation I'ro. <br /> . ..�' -- l„C" �' <br /> � ,� .� /'�.. . <br /> %t=%'/`' .,�=� _ �' ,��`.� .'. , ,, J / _< <br /> i��a . �"1-' !.. / / . y <br /> A h66riz Representative Signature Date <br /> .. �..' ..f' iL Y_x'v" <br /> ( <br /> l 3 7 fi 4 5 Neme o/Person!5ealing Well or Bonng <br /> LOCALCOPY H ' <br /> HE-01434•03 2/97 R <br />