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• <br /> WEc R BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 202122 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm-).Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 07 43-0003 24 OCT UZ • <br /> GPS Latitude degrees minutes seconds / <br /> LOCATION: Depth Before Sealing '73 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 Locationingle Aquifer 9 Multiaquifer <br /> 1530 Orchard Beach Place, Orono., <br /> Measured ❑ Estimated <br /> Water Supply Well 9 Monit.Well yf <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" location,showing property 0 Env.Bore Hole 9 Other D ft. below 0 above land surface <br /> N lines,roads,and buildings. <br /> ED xCASING1� TYPE(S) <br /> ---r---,----,-----,--- Steei 0 Plastic 0 Tile 0 Other <br /> W--r---,----r----, E WELLHEAD COMPLETION <br /> '::S. <br /> t.3,,,.14 <br /> Outside: ❑Well House Inside: 9 Basement Offset <br /> 10 <br /> 4 4 4 f hmrie Ns <br /> 30- . ❑ PitessAdapter/Unit Well Pit <br /> 0 Well Pit ❑Buried <br /> I I mAe i ..r { <br /> pl00 I , 0 Buried <br /> PROPERTY OWNER'S NAME/COMPANYNAtCASING(S) <br /> Ace Properties !63-694-88 <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above 2 r 1 � <br /> v in.from 0 to 6 ft. 9 Yes XNo 0 Yes 0 No 0 Unknown <br /> 5500 Anderson Estate Rd <br /> Maple Plaine,MN 55359 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Attn: Larry Palm in.from to ft. <br /> ❑Yes 0 No ❑Yes 9 No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME 3 of SCREEN/OPEN HOLE <br /> /� / / <br /> Well owner's mailing address if different than property owner's address indicated above Screen from YJ( to .2,,� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill 0 No Obstruction <br /> Type of Obstructions(Describe) ..../1//t. ' /9 ,f ‘14.-r. <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 JP t rump <br /> drift 0 73yRemoved 0 Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> XNo Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal <br /> IIIIII"'''' in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> Type of perforator <br /> 0 Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material NFA/ /4from (l to �3 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'? 0 Yes CXVo 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 /> COf1t9ctortluu Ines s: -ea Well .Drilling Co, , c277LicenserRegrr1 <br /> 10-29-02 __ <br /> •/or•c-. 'et nt r e ignakke Date <br /> Jim Antonson <br /> LOCAL COPY H 202122 <br /> Name of Person Sealing Well or Boring <br />