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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. .. H 4 4 81 2 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Minnesota Statutes,Chapter 103/ or W-series No. <br /> Hennepin (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm. •1g.) Date Sealed Approximate Date Well <br /> or Boring Constructed <br /> Orono IIB 21 15 42.4xxim /'9 OCT c3 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location / f ' <br /> 1005 old e / <br /> eke, R t Depth Before Sealing //0 ft. Original Depth + !O ft. _ <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level "Accurate <br /> in section grid with"X. location.showing property lines. <br /> N ........,,,,..... 1.-., . .;r.ads.aruf t tildlngss. 0 Approximate <br /> 1 \ t <br /> 1 .r/ I lJt6ingle Aquifer ❑Multiaquifer �tt. �` below above land surface <br /> • <br /> I t/ <br /> I t CASING TYPE <br /> W E �T <br /> r <br /> 1 , V mile . r <br /> • 1 ' feel 0 Plastic 0 Tile 0 Other <br /> ,' <br /> al <br /> S <br /> Hg--- Screen from f �' to " ft. Open Hole from to ft. <br /> r""le OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME 7bstruction 0 Debris 0 Fill ♦ er Cyt �g� ��/y <br /> of Type of debris/obstruction /AJ --I , tPL I- (G/i / ki /1' <br /> Mailing Address if different than property address indicated above. 3K <br /> es Riverside Ave Obstruction/Debris/Fill removed? ytTes ❑No <br /> riverside, CT 06878 PUMP f <br /> X.Fiemoved 0 Not Present 0 Other StA5 Po,7e <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known,indicate estimated formation log from nearby well or boring. t f <br /> drift 110 all in.from to F ft. ❑Yes to 0 Yes 0 No 0 Unknown <br /> 0 1 i(Y <br /> in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> o Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> 'j�9 in.from to ft. 0 Perforated 0 Removed <br /> .. in.from to ft. 0 Perforated 0 Removed <br /> 4�W4 <br /> Type of perforator <br /> ❑Other <br /> ' GROUTING MATERIAL <br /> DECt .LVW Grouting material,IV(/J/ CA Ill1rom o to fl c ft. yards 1 bags: <br /> from to ft. yards bags. <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards _ bags <br /> Grouted 4" well 110* deep from to ft. yards bags <br /> 9 bags cement UNSEALED WELLS AND BORINGS tom/ <br /> 10 lbs � Other unsealed well or boring on property? 0 Yes So <br /> 2 labor, ri ,� LICENSED OR REGISTERED CONTRACTOR CERTIFICATION' ` <br /> L.L 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 /> Don st a-• .le Well Drilling Co. I' <br /> Contractor Business Name 4 dense or R j rgNo. <br /> '`✓. _.._. i•---til" 17-83 <br /> Ae <br /> presentative Signature 63- <br /> Date <br /> LOCAL COPY H <br /> 4 4812Jim Antonson <br /> Name of Person Sealing Well or Boring <br /> HE-01434-01 <br />