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, .�- _, <br /> WELL oR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H � 2 4� 3 5 <br /> Counry Name <br /> WELL AND BORING SEALING RECORD Minn1e90 aoUnique No. <br /> Hennegin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank il not known) <br /> T wnship Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed � <br /> �rono 117 22 36 � � � 7/24/9? <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location <br /> I�4 Chev Chase Dr ive Depth Before Sealing 105 ry. Original Depih 105 n. E <br /> Show exact location of well or boring Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". ���� location, showing property �Single Aquifer ❑ MWtiaquifer <br /> �� j lines,roads,and buildings. <br /> N J WELUBORING �Measured ❑ Estimated <br /> �Water Supply Well ❑Monit.Well <br /> _ _ _Y_ _l__ _ __ <br /> ❑ Env.Bore Hole ❑Other �Z ft. [�below ❑above land surface <br /> yy --�- -�-- -�-- --i-- E CASING TYPE(S) <br /> --�- -i-- -i-- --�-- � � �$Steel ❑ Plastic ❑Tile �Other <br /> 14 mila � <br /> --�- -�-- -�-- --1-- � CASING <br /> � t 1 Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> `� g �! 1 <br /> �e--r mi�e � � "'^'�� 3 in.from � to 1 O 1 ft. ❑Yes [�No ❑Yes ❑No ❑ Unknown <br /> I � `_-�-��::-��__���-"^.� .-. .. "i.ct.�_.__.4.- <br /> .<-`�'�.^�""�`�",R <br /> PROPERTY OWNER'S NAME in.from to ft. ❑Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> Todd Shabert <br /> Proparty owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> Screen from t v 1 to 1 0� ft. Open Hole from to R. <br /> 09STRUCTIO WDEBRIS/FILL <br /> WELL OWNER'S NAME <br /> � Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing addieu if different than property owner's address indicated above. Type of Obstruction/Debns/Fill pum j�i , p i pa j e t <br /> Obstruction/DebrisiFill removed? � Yes ❑ No <br /> PUMP <br /> TYPe �@tr <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO '�'Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate astimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> C�r i f t O Ql�C � No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Pertoration/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br />� ❑ Other <br /> � GROUTING MATERIAL(S) <br /> GroutingMaterial P�rt�-alld from ld� to � ft. yards 4 ba s <br /> 9 <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to__ k. yards bags ` <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes 0:No <br /> LICENSEO OR REGISTERED CONTRACTOR CERTIFICATION <br />�� This well or borin was sealed in accordance with Minnesota Rules Cha ter 4725. The inf rm i n <br /> 9 , p o at o contained in this report is <br /> true to the best of my knowledge. <br /> R.E.S. We1.l Dxilling 2727� <br /> Contractor Business Name License or Registration No. <br /> �� r <br /> �'`', , ���� <br /> '.�'--�'L - �;i:/-_. f G_ /�� t / � <br /> Authorfzed Representative Signature Date <br /> Ja�s Lea <br /> LOCALCOPY H <br /> 12 4 8 3 5 Name o/Person Sealing Well or Boring <br /> HE-01434-02 . 10/95fi <br />