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WELL B LOCATION ° MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H S �t <br /> County Name WELL AND BORING SEALING RECORD M 1440 <br /> nnleso aoUnique No. _f14 <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank it not known) <br /> Township Name To am No. Range No. Section No. Fraction(sm.i Ig.) Date Sealed Date Well or Boring Constructed <br /> .Dt TonC; 117 . 23 04 u y y el Lit <br /> it- s + <br /> Numerical Street Address or Foe Number and City of Well or Boring Location <br /> 465 Orono Orchard Raaf- Orono, 1eth Before Sealing icle. ft. Original Depth 1 Ct 0 ft. <br /> p <br /> Show exact location of well or boring Sketch map of well or boring QUIFER(S) STATIC WATER LEVEL <br /> n section grid with 7C_ 5539 1 location. showing property Single Aquifer 0 Multiaquiter <br /> lines,roa s.and buildin S{ <br /> N � st-x."ape • ,,p�-i.> ` , WELL/BORING %Measured 0 Estimated <br /> • i" Nater Supply Well 0 Mond.Well p <br /> "-T--T-r71----4-- <br /> l { 0 Env.Bore Hole 0 Other I f 0 ft. below 0 above land surface <br /> W E i CASING TYPE(S) <br /> 1 1 I �++1t ' r° <br /> "'}"—'- ---�"-"f-' T t-- t�" Steel 0 Plastic ❑Tile 0 Other • <br /> 1 1 1 1 re aw . <br /> --+--+---+---+-- i �,m, .. CASING <br /> Diameter Depth t Set in oversize hole? Annualar space initially grouted? <br /> t S -.1-1 r i/ 'q <br /> eF—t mi i � _ .—' in.from 0 to / 8 ft. 0 Yes to 0 Yes 0 No 0 Unknown <br /> PROPERTY OWNER'S NAME Ycri: c, Constr. in.from to ft. 0 Yes ElNo ❑Yes 0 No 0 Unknown <br /> Pmpsrlymoots maim address d dllerent than well location address indicated above. infrom to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> 27741 University Ave s N. SCREEN/OPEN HOLE <br /> Isr` nti, Mn. 55040E' A ? / <br /> Screen from I C;k . to / c ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OMER'S NAME �f <br /> ❑ Rods/Drop Pipe 0 Check Valve(s) ❑Debris 0 Fill No Obstruction <br /> Wee owns ming adpees a&Craw men property owner's address indicated above. Type of Obstructions(Describe) <br /> Obstructions removed? ❑Yes 0 No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO 0 Removed ( Jot Present 0 Other <br /> FORMATION <br /> a not known.ete esaalmmeetonesCon log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING ANDBORE HOLE: <br /> _ JNo Annular Space Exits <br /> ,tet Y <br /> t w - 0 Annular space grouted with traria pipe <br /> ti 0 Casing PerforatiorVRemoval <br /> 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) • <br /> Grouting Material/ 4 r` ri.. :4'J/from C) to/If' R. yards 8+ bags <br /> from to ft yards bags <br /> from to R yards bags <br /> from to ft. yards bags <br /> REMAIL,SOURCE OF DATA,DIFRCULTIES IN SEALWG OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? 0 Yes to How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The adorrrnEan,.,mimed in this report is <br /> true to the best of my knowledge. <br /> DON &`IC•DCLA WELL DRILLILG CO. , INC. 27172 <br /> ,- Contractor Business Name License or Raga:Oman No. <br /> t' <br /> ,-). 'L: '' '—,‘, ,,,--,t;:(.-`..,i7..."7••^'- ._-_,47 -.) ' ' -) _.-.....,./ -- - (--- , <br /> Affit Representefhre Siprtatuftii I t• i <br /> , <br />