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MINN:SOTA DEPARTMENT OF HEALTH Sealin Minnesota Well and Boring L� e <br /> WING LOCATION IVO. f7 <br /> WELL AND BORING SEALING RECORD Minne9ota Unique Well No. r— <br /> `/'1f' <br /> ii <br /> Minnesota Statutes.Chapter 1031 or W-series No. <br /> 5 <br /> riapain (Leave dank H not known) <br /> Township Name Township No. Range No Section No. Fraction Ism - Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 07 43-0003 r. 7e 7--k-T-t z, . <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> r r <br /> 153(? Orchard Beach Place, t 0fl epthBetoreSealing ft. Original Depth h <br /> Show exact location of well or boring Sketch map of well or boring A�OyUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property SA Single Aquifer ❑ Multiaquifer <br /> ; SlOads,and buildings. •,g{GJ <br /> N A i WELUBORING : Measured ❑ Estimated.1 Water Supply Well ❑Monit.Well <br /> '-`- ❑ Env Bore Hole ❑Other _. ft. (below ❑ above land surface <br /> i CASING TYPE(S) <br /> --- 41 � '�,Vi)) f�/.�teel 5 Plastic ❑The ❑ Other __ <br /> f I Yzmb 'j 1 CASING(S) <br /> i 1 <br /> i ) <br /> ' <br /> , I Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> ll 4/S1 I <br /> It�r mile <br /> 41'j in.from tot ft. ❑ Yes ((No ❑ Yes 5 No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> Ace Properties ) 763-694-8800 ' <br /> Property owner's mailing address if different than well location address indicated abovein.from to ft. 5 Yes ❑ No 5 Yes 5 No ❑ Unknown <br /> 5500 Aderson Estate Rd SCREEN/OPENHOLE <br /> r <br /> Maple Plain, MN 55359 ,� —, <br /> h <br /> ,t^ 7 Screen from to . Open Hole from to ft. <br /> At t n:Larry Palm OBSTRUCTIONS <br /> WELL OWNER'S NAME .liFlods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailingaddress if different than roe owner's address Indicated above. 7� /Fire_ Ci fry-) <br /> properly rty Type of Obstructions(Describe) /�./�r>�i �` <br /> Obstructions removed? (1'es ❑ No Describe <br /> PUMP <br /> Type /,/2 PC/M/2 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �' RemovedV I=1Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> XAnnular Space Exists <br /> '-..f - = ❑Annular space grouted with tremie pipe <br /> ,j ❑Casing Perforation/Removal I <br /> in.from to ft. 5 Perforated ❑ Removed <br /> in.from to ft. 0 Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of;cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> ( <br /> Grouting Material 1J /of r elft':�fiern' n to sq ft. yards FS'-' _ be <br /> from to ft. yards <br /> from to ft. yards ' <br /> from to_ ft. yards <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS ,{,� <br /> Other unsealed and unused well or boring on property? 5 Yes L>CNo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in <br /> true to the best of my knowledge. <br /> soon stodola Well Drilling Co, - inc- 2717' <br /> Contractor Business Name - License or Registration <br /> . ////,, I ° is /�� <br /> •T,,../77: <br /> ithpnfed resentative Signature.- Date <br /> 1 <br /> H ��� �� Name of Person Sealing Well or Boring <br /> LOCAL COPY 9 <br />