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MINNESOTA DEPARTMENT OF HFALTH M�nnesota Well and Bor�ng � A n <br /> WEIL OR BORING LOCATION I ��y�7 y�� <br /> WELL AND BORING SEALING RECORD Sealing No I�"� �, i �� <br /> County_Name Minneso!a Unique Na � � I <br /> Nennepin Mmnesota Statutes.Chapter 1031 or W-senes No. <br /> ILea�e biank il no�known� <br /> . Township Name Township No. Range No. Secfion Na Fracuon(sm.�Ig.) Date Sealed Date Well or Bonng Constiucted � <br /> Orono 118 2 36 4i-9p3 �2 �;� � <br /> Numerical Street Atldress or Fire Number and Ciry of Well or Bonng Location � � <br /> lfld Chevy Chase �L`� �r��� Depth Before Seahng ��� _ft Original Depth ��� n <br /> Show exact Iceation of well or bonng Sketch map of well or nng ppUIFER(S) STATIC WATER LEVEL <br /> - in section gnd wdh"X'. IocaGon, showing pro e, �j Single Aywter ❑ Multiaquder <br /> lines,roads,and buddin s�. �( ' <br /> N �. WF,�UBORING 'Ll Measuretl ❑ Estimated �� <br /> ' .�.�.��..... ...----..-....� .,3 L�Water Supply Well ❑Monit Well � �I - <br /> - - - - - - t <br /> ❑ Ern.Bore Hole ❑Other _ fl. �below ❑above land suAace <br /> W -�- -i-- - -- --i- E ..•, CASING TYPE(S) <br /> ' � � � � ._._..._...� `i - <br /> � -�- -�- -�-- --�-- � �-`=���T . ,' Steel ❑Plastic ❑Tile ❑Other <br /> �c mde �'"'y� <br /> � � CASING <br /> -�-- 1-- --�-- � Y�' <br /> ,t Diameter /� Depth t� � Set in ove�size hole? Annualar space mi6alty groutetl? <br /> S � �! i✓ � T� Ves No ❑ Unknown <br /> �y.--i m�re—�» _ ,.,.,, �--'E _ ~}'- ' ..s in.trom to tt. ❑ ves �lo ❑ ❑ <br /> PROPERTY OWNER'S NAME -�" in.from to fl. ❑ Yes ❑No ❑ Yes ❑Na ❑ Unknown <br /> P�opeM a+'^ei s mailing adtlreu if ditt rent than well location address indicated above. in.from to fl. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> ���Ml�i Ryerse 475����U SCREEWOPENHOLE . � f <br /> 7 y <br /> 1�.�.��� � L,,;,,�.., y_.! • Screen from �L�'-`, to �-'�" ft. Open Hole trom to ft. <br /> - ��� { OBSTRUCTIONS <br /> �.�..3� .y._, �,.> <br /> WELL OWNER S A' �Y �Rods/Drop Pipe ❑Check Valv=(s) ❑ Debris Iy--I„Fill ❑ No Obstryction <br /> Well owners maihng address it diflarent t�an property owner's adtlress indicated above. Type ot Obsl�uctions(DeSCribe) �"`����, " �� � S��• <br /> Obstruclians removed? �Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOCi1CAL MATERIAL COLOR MARDNESS OF FROM TO � Removed L�Not Present ❑ Other � <br /> If not krawn,indicate estimated tortnatbn log from nearby wORM�Og METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �� <br /> �r��� O �� �No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> � ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ PeAorated ❑ Removed <br /> in.from to fl. ❑ Pertorated ❑ Removed <br /> Type of pertorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> / <br /> Grouting Material ti�`�� r'�/,�'-G�f�m � to /� fl. yards � begs <br /> from to fl. yards bags <br /> from -to � fl. yards beys <br /> from to__ tt. yards Dags <br /> '- REMARKS,SOURCE OF DATA,DIFflCULTIES IN SEALING OTHER W ELLS AND BORINGS <br /> � Other unsealed and unused well or bori�g on property7-0 Yes- ,�Jo How many? - - -- - ` <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> ;. This well or bonng was sealed in accardance with Minnesola�Aules,Cfiapter 4725.�The inlortnation contained in lhis report ie '� <br /> � true to the best of my know�edge. <br /> � I)on StodolaWell Drill�n� Co:; -Inc. 2?1�72 ' <br /> Contractor Business Name License or Regishation fvo. <br /> �-;�f r�� �� ;=�-'`� :�-�r �4-13-9 9 <br /> tho ed Representative Signeture _. ,_ Date ' <br /> Jim Anion��xt <br /> � _ . , <br /> H e Name o!Person Seali�Well a Boring <br /> d.O�AL C(3r�Y J <br /> HE-01434-04 8/98 R <br />