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v�(EL4 OR.�ORMIG LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 0 213 2
WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No.
County Name ---
� Aennepin Minnesota Statutes,Chapter 1031 or W-series No.
(Leave hlank�ii no�known)
Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed
Orono 117 23 17 4;.Otl.�l ,. � O!/ Z
GPS Latitude degrees minutes seconds � � �
LQCATION: Depth Before Sealing �� ft. Original Depth � ft.
Longitude degrees minutes seconds qQU1FER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer
192Q Shadywood Rd, OCOIZO WELUBORING �(Measured ❑ Estimated
`�Water Supply Well ❑Monit Well
Show exact location of well or boring (� Sketch map of well or boring �
in section grid with"X° �{_ location,showing property ❑ Env.Bore Hole ❑Other _,��_ _ft. �elow ❑above land surface
�� lines,roads,and buildings.
N CASING TYPE(S)
' �(,V, I]CSteel ❑ Piastic ❑Tile ❑Other
T
W -- - -- - — -- -- E � i
WELLHEAD COMPLETION
� � � � � Outside: ❑Well House Inside: ❑Basement Offset ��
-�— -�-- -;-- --�-- �- -�
� � � � ` �.�
y�mi�e '�. � �itessAdapter/Unit ❑Well Pit
� � � � �_,
-�-- -i— -�-- --i— I
1 � ❑Well Pit ❑Buried
S
�i mee—�. �'— .
❑Buried
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
� � Diameter � Depth / Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above � �/�
� in.from� to��lft. ❑Yes �No ❑Yes ❑No ❑Unknown
I133 Thorn St
.7 C Pa�1� I�N 5 5106 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑ Unknown -
in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
I /
Well owners mailing address if different than properry owner's address indicated above Screen from�t0�ft. Open Hole from t0 ft.
OBSTRUCTIONS -
(�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe)�itliU����r� ¢ �!J/�P
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 2S ❑ NO DOSCrlb2
FORMATION -
If not known,indicate estimated formation log from nearby well or boring PUMP ' .
TYPe S�J PC1C�-�
�Removed ❑ Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�lo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
i
Grouting Material � m—�_to—��ft. yards � bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes No How many?
LICENSED OR REGISTEflED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is
true to the best of my knowledge.
. .�_ , � ��.`�i Dnt� Stodala Wcs11 Dr�17 i n�� TnC_ 27I72
I /� Contractor Business Name `^e� License or Regislration No.
i�^,ol N [_ � �Ppl!7 f/
� �! ,/v� O Z
� .. ._ _ ' '
��';� �y� ��„����a A t ive ignatur€�'� ��� �� Date
..,`\\ ;�--�-, ��
LOCAL COPY H 2 O 2 1 3 2 Name of Person Sealing or Boring �