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WELL oR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H � 2 4� 3 5
Counry Name
WELL AND BORING SEALING RECORD Minn1e90 aoUnique No.
Hennegin Minnesota Statutes,Chapter 1031 or W-series No.
(Leave blank il not known)
T wnship Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �
�rono 117 22 36 � � � 7/24/9?
Numerical Street Address or Fire Number and Ciry of Well or Boring Location
I�4 Chev Chase Dr ive Depth Before Sealing 105 ry. Original Depih 105 n. E
Show exact location of well or boring Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL
in section grid with"X". ���� location, showing property �Single Aquifer ❑ MWtiaquifer
�� j lines,roads,and buildings.
N J WELUBORING �Measured ❑ Estimated
�Water Supply Well ❑Monit.Well
_ _ _Y_ _l__ _ __
❑ Env.Bore Hole ❑Other �Z ft. [�below ❑above land surface
yy --�- -�-- -�-- --i-- E CASING TYPE(S)
--�- -i-- -i-- --�-- � � �$Steel ❑ Plastic ❑Tile �Other
14 mila �
--�- -�-- -�-- --1-- � CASING
� t 1 Diameter Depth Set in oversize hole? Annualar space initially grouted?
`� g �! 1
�e--r mi�e � � "'^'�� 3 in.from � to 1 O 1 ft. ❑Yes [�No ❑Yes ❑No ❑ Unknown
I � `_-�-��::-��__���-"^.� .-. .. "i.ct.�_.__.4.-
.<-`�'�.^�""�`�",R
PROPERTY OWNER'S NAME in.from to ft. ❑Yes ❑No ❑ Yes ❑ No ❑ Unknown
Todd Shabert
Proparty owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
SCREEWOPEN HOLE
Screen from t v 1 to 1 0� ft. Open Hole from to R.
09STRUCTIO WDEBRIS/FILL
WELL OWNER'S NAME
� Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailing addieu if different than property owner's address indicated above. Type of Obstruction/Debns/Fill pum j�i , p i pa j e t
Obstruction/DebrisiFill removed? � Yes ❑ No
PUMP
TYPe �@tr
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO '�'Removed ❑ Not Present ❑ Other
FORMATION
If not known,indicate astimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
C�r i f t O Ql�C � No Annular Space Exits
❑ Annular space grouted with tremie pipe
❑ Casing Pertoration/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
� ❑ Other
� GROUTING MATERIAL(S)
GroutingMaterial P�rt�-alld from ld� to � ft. yards 4 ba s
9
from to ft. yards bags
from to ft. yards bags
from to__ k. yards bags `
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ Yes 0:No
LICENSEO OR REGISTERED CONTRACTOR CERTIFICATION
�� This well or borin was sealed in accordance with Minnesota Rules Cha ter 4725. The inf rm i n
9 , p o at o contained in this report is
true to the best of my knowledge.
R.E.S. We1.l Dxilling 2727�
Contractor Business Name License or Registration No.
�� r
�'`', , ����
'.�'--�'L - �;i:/-_. f G_ /�� t / �
Authorfzed Representative Signature Date
Ja�s Lea
LOCALCOPY H
12 4 8 3 5 Name o/Person Sealing Well or Boring
HE-01434-02 . 10/95fi