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WELL 011 @011111G LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 107 13Seating <br />8 <br />County Name WELL AND BORING SEALING RECORD M nnesotaoUnique No. <br />Hennepin Minnesota Statutes, Chapter 1031 or W-senes No. <br />(leave N.* it nit k--) <br />Township Noma Township No. Range No. Section No. Fraction Ism. -w Ig.) Date Sealed Date Well or Boring Coinstnrcted <br />Orono 117 23 4 8/22/96 <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />60 Cygnet Place Depth Before Seating 1� It. Original Depth 1,1,E h <br />Show exam location of well or boring Sketch map of well or boring AOUWEIyS) STATIC WATER LEVEL <br />in section grid with'X'. /,'� location, showing Property e A urfer <br />Imes. roads, and buildings �i^91 q ❑ Muffiaginfer <br />N WELLIBORING Z Ide.iswed Esi-aled <br />-T- -+- -*- -i-- Cfaler Supply Well ❑ Mont Well <br />❑ Env Bore Hole ❑ Other _ it belox C above land surface <br />W "+' -'�'- 't I E _ CASING TYPE(S) <br />4- -?'- 4- []Seel ❑ Plastic ❑ Tile ❑ Other <br />4 mxa <br />-i I CASING <br />l � 1 Diameter Depth Set in oversize hotel Annualar space initially <br />itialty grouted? <br />aft-- fins.--�Ir _,4 in Irom _0._ to — It ❑ Ye5 No �' Yes ❑ NO El Unknown <br />PROPERTY OWNER'S NAME In from -_ to __ It ❑ yes ❑ No ❑ yes ❑ No ❑ Unknown <br />Dan Currier <br />Property owner s mal, g ad9niss d a flerent than won location address indC led above ) Irom _ _ to _ h ❑ Yes ❑ No ❑ Yes ❑ No []Unknown <br />SCREENIOPEN HOLE 1 <br />Screen lion,_�-._ to _.1,..a3_ ft Open Hole from to _ tt <br />OBSTRUCTIO WDEBRIS/FILL <br />WELL OWNER'S NAME LAObstructnon ❑ Debris ❑ Fill ❑ No Obstruction <br />Wee ow+*es mNkg address it different than property owner's address indicated above Type of Obstruction Debns/Fdl Pump S—Yi e — <br />ObstnutiOrVDebnsfFill removed? [ki Yes ❑ No <br />PUMP <br />rT-yype Su. aelrgj�ble <br />GEOLOGICAL MATERIA'. COLOR ��ASS N FROM TO YC'emoved ❑ Not Present ❑ Other <br />If not known. indicate estimated formation fog from nearby wee or boring METHOD USED 10 SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: <br />drift 11 EkNo Annular Space Exits <br />❑ Annular space grouted with trem-e pipe <br />❑ Casing PerloratrontRemoval <br />in from to _ It ❑ Perforated ❑ Removed <br />in from to _ ft [I Perforated ❑ Removed <br />Type o! perforator <br />❑ Other <br />GROUTING MATERIAL(S) <br />---- Grouting Matenal 'pQ'., bland - from _ 11310 _$ It _ yards —19 bags <br />from to If yards bags <br />from to ff yards bags <br />from to ft. yards bags <br />IREMAINKS, SOURCE OF DATA, DIFFICULTIES IN SEALING UNSEALED WELLS AND DOP44GS <br />Other unsealed well or boring on property? ❑ Yes <br />LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br />This well or boring was sealed in accordance with Minnesota Rules. Chapter 4725. The udm oratgn contained in this report is <br />true to the best of my knowledge. <br />SAP R-W.S.- Nall Ori21+r,] 27276 <br />Contractor Business Name License or Registration No. <br />4r <br />AuMonred Fleoresen!- aaT ^Sprafura Date <br />LOCAL COPY FH-11 0 713 8 "° ' 4M., <br />HE-01�74-02 lflw <br />