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,il► <br /> WELltR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 202121 <br /> 2121 <br /> County Name <br /> WELL AND BORING SEALING RECORD So. <br /> ealing <br /> Minnesotanique Well No. V <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank If nd kn wn) <br /> Township Name Township No. Range No. Section No Fraction(sm-.Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 07 43-0 Q3 <br /> 2cj OCT C)2 <br /> GPS Latitude degrees minutes seconds h I <br /> LOCATION: Depth Before Sealing 7d ft. Original Depth �� ft. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring LocationSingle Aquifer ❑Multiaquifer <br /> 1530 Orchard Beach Place, Orono ELUBORING Measured El Estimated <br /> ater Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" location,showing property Env.Bore Hole Ill Other ft. PI below PI above land surface <br /> N ( lines,roads,and buildings. CASING TYPE(S) <br /> r---,----,----- _- 0 ( Steel ❑ Plastic ❑Tile ❑Other <br /> W E WELLHEAD COMPLETION <br /> - i----.--- , , <br /> vN 1�1 Outside: ❑Well House Inside: ❑Basement Offset <br /> 9 r <br /> f 1 i thmr� 0�3N,�D ❑Pitess Adapter/Unit Nell Pit <br /> ---1-H----i t ' I <br /> c, ❑Well Pit ❑Buried <br /> S 1 LI <br /> 11,. I mge- 4 1. _ <br /> ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME n p /� CASING(S) <br /> Ace Properties 763-694-8800 Diameter„ Depth , Set in oversize hole? Annular space initially grouted? <br /> Properly owner's mailing address if different than well location address indicated above <br /> In.from b to_41,41:ft. ❑Yes 1)I(lo ❑Yes ❑No ❑Unknown <br /> 5500 Adderson Estate Rd <br /> Maple Plain, MN 55359 in.from to ft. ❑Yes ❑No ❑Yes ❑No El Unknown <br /> At t n:Larry Palm in.from to ft. ❑Yes ❑No ❑Yes ❑No El Unknown <br /> WELL OWNER'S NAME/COMPANY NAME r. SCREEN/OPEN HOLE <br /> i // ,, ...... 1 <br /> Well owner's mailing address if different than property owner's addred dicated above Screen from C.e�COto 7C./ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe El Check Valve(s) El Debris El Fill ),,No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑ No Describe <br /> FORMATION - . — <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Type <br /> drift 0 . 70 ❑ Removed p(Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> Llo Annular Space Exists ❑ Annular space grouted with tremie pipe El Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated El Removed <br /> Type of perforator <br /> • <br /> El Other _ <br /> GROUTING MATERIAL(S) (One bag of cement w 94 lbs.,one bag of bentonite w 50 lbs.) <br /> Grouting Material 40.&-47(”_2)T from O to_ Z ft. yards 3 bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yeso 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 this report is <br /> true to the best of my knowledge. <br /> CPRidr B ir12S5 5l a Well Drilling Co. L Jnecr 4eg2r7 72 <br /> �— /-//�! 10-29-02 <br /> oozed Representative Sig -ur- Date <br /> LOCAL COPY <br /> H 202121Jim Antonson <br /> Name of Person Sealing Well or Boring <br />