HomeMy WebLinkAbout2016-01513 demo , CITY OF ORONO * Z � 1 6 - 0 1 5 1 �
2750 KELLEY PARKWAY DATE ISSUED: 12/02/2016
ORONO, MN 55356-
(952) 249-4600 FAX: (952) 249-4616
ADDRESS : 3907 CHERRY AVE
PIN : 08-117-23-33-0027
LEGAL DESC : CRYSTAL BAY VIEW
: LOT 000 BLOCK 006
PERMIT TYPE : DEMOLITION
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : DEMO-PRINCIPAL STRUCTURE
NOTE:
1. FOUNDATIONS/ALL DEMO DEBRIS TO BE REMOVED FROM GROUND&DISPOSED OF OFF S[TE,PER PCA REGULATIONS.
2. WELLS MUST BE ABANDONED.
3. INSPECTIONS DONE BEFORE BACKFILLING.
NO"I'E: A 24-48 HOUR NOTICE[S REQUIRED FOR ALL INSPECTIONS. CALL(952)249-4600.
SEWER MUST BE DISCONT[NUED AT THE CITY SERVICE BY QUALIFIED CONTRACTOR BEFORE DEMO PERMIT IS ISSUED. CHECK
TO MAKE SURE TH[S PERMIT HAS BEEN PULLED BEFORE ISSUING THIS PERM[T.
APPLICANT
PR[DE CONSTRUCTION& EXCAVATING TOTAL
9450 WEST HILL ROAD Payment(s)
WATERTOWN, MN 55388
(952)475-2928
OWNER
I[l,GERALD CLARK
870 CHERRY AVE
MOUND, MN 55364-
AGREEMENT AIYD SWORI�STATEMENT
The work for which this permit is issued shall be performed according ro
the approved plans and specifications,applicable Ciry approvals,and the
State Building Code. This permit is for only the work described and does
not grant permission for additional or related work which requires separate
permits. All provisions of laws and ordinances governing this type of work
shall be compied with whether or not specified herein.This permit will
expire and become null and void if construction authorized is not
commenced within 180 days of the date of issuance,or if construction is
suspended for a period of 180 days at any time after work has commenced.
The applicant is responsible for assuring all required inspections are
requested in conformance with the State Building Code.This permit may be
revoked at any time for due cause. ,
- Z--°� �J /�� � 1 �
Applicant Permitee Signature Date sue E3y Si ature Date
+ ��T City of Orono OR ITY SE ONLY,
� i VO P.O.Box 66 Date Received:�2"��� ermit# �� S��
2750 Kelley Parkway � )
Crystal Bay,MN 55323 Amount: $ N SAC Credit:
� �. Phone:(952)249-4600
y � Homeowner(s)Signed: ❑Yes
F'� �,� Fax: (952)249-4616 Resolutions(if any)Signed:❑Yes ❑None Required
qkFSH��� Zonin Disclosure Si ned: ❑Yes ❑None Re uired
CITY OF ORONO - DEMOLITION PERMIT
(All permits must be approved by the Building Official and/or Zoning Department)
Job Site / Owner Information:
Type: �Residential ❑ Commercial
.� �;
Site Address: -� ��� � L � '.��� v'� .����� �° �'C'
., " �
/ �
Owner:(<�6"cc�� � ��,�,�- � `�Mailing Address: `-�°U �r1 �
,
City: i�'��1� ��l �'�✓ Zip: �'.,��,7 ��ri
Phone: ' Email: �
Contractor/Applicant Information:
Contractor/App.: r�r�� ��t��` �'�C�G'�'f�_�c; Contact Person: �� No 1 (��'1'��-li���;�Ic='
�� _
Address: `"� %� �� ��u'r� /��� 1��C1 State License #:
City: ��,(�"����G'����� ���Zip: �_7 . � ��� Expiration Date:
�
r
Phone: `���`�- �--� ��G "� <<'� �� Email:
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SPECIAL CONDITIONS � HOLD HARMLESS AGREEMENT
General I nstructions:
1. You may be required to obtain other permits, i.e.: well abandonment, sewer, etc.
2. Work must not begin unless the permit card is available on the job site.
3. A 24-48 hour notice is required for all inspections. Call (952) 249-4600.
4. Sewer must be discontinued at the City service by qualified contractor before demo permit is issued.
Demolition by means of: ❑ Manual Disassembly�Heavy Equipment ❑ Other
Permit(s) Issued: ❑ Sewer Disconnection ❑Well Abandonment#
In return for issuance of said Demolition Permit, the undersigned owner hereby agrees to:
1. Submit a survey, aerial photo or sketch showing all structures on the property. Note which structures are
to be demolished.
2. Submit a survey, aerial photo or sketch showing proposed erosion control measures in accordance with
Chapter 79, Construction Site Runoff Control.
3. Submit a copy of permit approval from the Minnehaha Creek Watershed District (MCWD). The City will
not issue a demolition permit without a copy of the permit(s) from the MCWD or documentation stating
permit(s) are not required.
Form Last Updated: July 2015
150784
. ,
4. Submit a$2,500 escrow and an escrow agreement signed by the property owner(copy attached).
5. Keep all structure(s) enclosed and/or secured until such time as demolition is complete.
6. Keep all demolition debris off adjoining property and/or the public rights-of way unless specific prior
approval is obtained in writing for temporary use thereof.
7. Completely remove foundation(s) from the ground.
8. Completely dispose of all demolition debris off site in accordance with all applicable PCA requirements.
9. Abandon water wells in accordance with State Health Department regulations.
10. Call for an inspection when all debris has been removed, before backfilling.
11. Within 5 working days of superstructure removal, a final inspection shall be requested. The site shall be left
clean and clear of all debris, with any excavation filled with earth level with the adjacent ground elevation '
(except when such excavation is to be used as part of a new building and such new building is actually
under construction).
12. Abandon septic systems per Minnesota Rules Chapter 7080. All septic tanks must be pumped, crushed
and filled with native soils. An inspection is required after the tanks are pumped and before the tanks are
crushed and filled.
13. The undersigned owner shall and hereby does indemnify and hold harmless the City of Orono, its agents,
employees and assigns from and against all claims, damages, losses or expenses, including attorney fees,
against the City, its agents, employees and assigns arising out of or resulting from the demolition described
herein as performed by the property owner, his employees, agents, subcontractors or assigns.
PERMIT TYPE AND FEE CALCULATION
❑ $75.00 — Principal Structure $ C-
❑ $50.00 —Accessory Structure x (how many)
1. Subtotal of above permit requested $
�, /
2. State Surcharge i l,i/� �
(;
3. TOTAL PERMIT FEE (add lines 1-2 above) $ �;-��
The undersigned herby applies to the City of Orono for issuance of a Demolition Permit, agrees to do all
the work in a strict accordance wi the ordinances of the City and the regulations of the State of
Minnesota, and certifies that all st me de n t � complete, true and correct.
Applicant's Signature: Date: �C ` 2 _ /�
Owner's Signature: Date:
, i
Approved By: � �"��� �F�' '' Date: !% '�� i c%.
�= � (�uilding icial) `
* Zoning Disclosure Required? ❑ YES NO
*This must be filled out by Zoning Department—For e� er answer, a Zoning Official must sign all applications.
* Approved By: Date:
(Zoning Official)
Form Last Updated.� July 2015
150784
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DATE TIME
CITY OF ORONO CALLED IN
INSPECTION NOTICE SCHEDULED
PERMIT NO. �4�G"C�l.►��� COMPLETED �L:� Z saT9
ADDRESS s ID 7 ��'W�^
OWNER TELEPHONE NO.
CONTRACTOR
� DESCRIPTION ��i�0 aG� • '�ll
ly ❑ FOOTING ❑ DEMO-FINAL ❑ SEPTIC FINAL
Q ❑ POURED WALL
❑ PLUMBING RI EXCAV/GRADING/FILLING
y ❑ FOUNDATION WATERPROOF ❑ PLUMBING FINAL ❑ REE REMOVAL
Z ❑ RADON SLAB ❑ MECHANICAL RI ❑ SITE INSPECTION
Q ❑ FRAMING ❑ MECHANICAL FINAL ❑ RATED WALLS
� ❑ INSULATION ❑ WOOD BURNER/FIREPLACE ❑ COMPLAINT
Q ❑ FINAL ❑ WATER HOOK-UP ❑ FOLLOW-UP
W ❑ AS BUILT-SURVEY ❑ SEWER HOOK-UP ❑ FOUNDATION/REMOVAL
_
J ❑ DEMO-SITE ❑ SEPTIC INSTALL
2 OWNER/CONTRACTOR TO MEET YOU:_YES_NO
� COMMENTS:
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W �WORKSATISFACTORY:PROCEED ❑ PROJECTCOMPIEfE
� CORRECT 1MORK S PROCEED � , ' ���s ❑ ISSUE CERTIFICATE OF OCCUPANCY
�RRECT WORK,CALL FOR REINSPECTfON` �� TEMPORARY
V BEFORE COVERING PERMANENT
❑CORRECT UNSAFE CONOITION WITH�����HOURS. ❑ PHOTO TAKEN
INSPECTOR WILL REfURN .�"�
❑STOP ORDER POSTED.CALL INSPECTOR �CITATION ISSUED
❑INSPECTION REQUIRED.CALL TO ARRANGE ACCESS.
Call for the next inspection 24 hours in advance. (g52) 249-4600
OwnerlContra n site:
Inspecto�
White Copy/lnspector's File Canary CopylSite Notice
� M
Pre-Demolition Hazardous Buiiding
Materials Inspection Report
esidential
3907 Cherry Avenue
oun ,
Prepared for
Pride Construction
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Project B1611189
• November 30,2016
. �
• � Braun Intertec Corporation
�: ,, :
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• i
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B��� � Braun Intertec Corporation Phone:952.995.2000 f
11001 Hampshire Avenue 5 Fax: 952.995.2020
Minneapolis,MN 55438 Web: braunintertec.com �
INT�RTEC �
The Sdence You Build On.
November 30, 2016 Project B1611189
Mr. Ken Vanderlinde
Pride Construction
9450 West Hill Road
Watertown, MN 55388
Re: Pre-Demolition Hazardous Building Mate�ials Inspection Report
Residential House
3907 Cherry Avenue
Mound, Minnesota
Dear Mr.Vanderlinde:
The enclosed report provides the results of the pre-demolition hatardous building materials inspection
conducted on November 29,2016,at the residential house located at 3907 Cherry Avenue in Mound,
Minnesota (Site). Braun Intertec Corporation was authorized to conduct this inspection in accordance
with our Authorization for Services QTB049163 dated November 25, 2016 and the Braun Intertec
General Conditions.
The following outline provides the structure of the report.
• Scope of Services
- Site Description �
• Results
• Discussion
• Limitations
If you have any questions or need further assistance, please call Eric Bieniek at 612.834.4627 or
Steve Luth at 952.995.2662.
Sincerely,
BRAUN INTERTEC CORPORATION
�
� �� _ .�
/./`��-S�`-.--`'�`--'.
Eric W. Bieniek
Environmental Technician
i�t �� � r .
Stephen A. Luth `bo,c
Project Scientist
Attachments:
Pre-Demolition Hazardous Building Materials Inspection Report
,aA/i�:or
�
, r
Table of Contents
Description Page
A. Scope of Services..............................................................................................................................1
B. Site Description ................................................................................................................................1
C. Results..............................................................................................................................................1
C.1. Asbestos..............................................................................................................................1
C.l.a. Asbestos-Containing Materials..............................................................................2
C.1.b. Non-Asbestos-Containing Materials......................................................................2
C.2. Lead-Based Paint.................................................................................................................3
C.3. Miscellaneous Regulated Waste.........................................................................................3
C.3.a. Mercury..................................................................................................................4
C.3.b. Miscellaneous.........................................................................................................4
D. Discussion.........................................................................................................................................4
D.1. Asbestos-Containing Materials ...........................................................................................4
D.i.a. Friable ACM............................................................................................................4
D.l.b. Category II Non-Friable ACM..................................................................................5
D.2. Lead-Based Paint.................................................................................................................5
D.3. Miscellaneous Regulated Waste.........................................................................................5
E. Limitations........................................................................................................................................5
F. Asbestos Inspector Certification ......................................................................................................6
Appendices
A: Table I. Asbestos Building Inspection Results
B: Table II. Bulk Asbestos Analytical Results
C: Bulk Asbestos Analysis Reports
D: Asbestos Inspector Certificate
sRAUN
INTERTEC
A. S�ope of Services
The scope of our services was limited to:
■ Visually examine accessible areas and identify locations of suspect asbestos-containing
material (ACM), lead, poly-chlorinated biphenyls(PCB), mercury, and other miscellaneous
hazardous material.
■ Collect and analyze representative bulk samples of materials suspected of containing
asbestos.
■ Assign a hazard rating based on asbestos content with respect to the materials condition,
friability, accessibility, and hazard potential.
■ Document the various materials' current conditions and ACM quantities.
■ Generate a final report documenting the sample locations, analysis results, conditions,
ACM quantities and recommendations.
B. Site Description
The subject of the inspection is the residential house located at 3907 Cherry Avenue in Mound,
Minnesota.The house is a two-level wood structure with a basement. It was originally constructed in
1930 and encompasses approximately 1,925 square feet.The house is constructed of wood,concrete
and concrete block foundation walls.The typical interior finishes included sheetrock/joint compound,
floor tile,wood flooring and vinyl sheet flooring.The exterior of the house has wood and plastic siding
with an asphalt roof shingle system.A detached garage that it is on the property is constructed of wood
and has an asphalt roof shingle system as well but is not included as part of this inspection.
C. Results
C.1. Asbestos
Twenty-three (23) bulk samples were collected on November 29, 2016 and submitted to EMSL Analytical,
Inc., a microscopy laboratory that is fully accredited for asbestos bulk analysis.
eRauN
INTERTEC
Pride Construction
Project 61611189
November 30, 2016
Page 2
C.1.a. Asbestos-Containing Materials
The following is a summary of building materials found or assumed to contain greater than one percent
asbestos(asbestos-containing materials by regulatory definition).
■ 1-3" millboard pipe insulation with tarpaper layers in the basement contains 40 percent
chrysotile (asbestos).
■ Adhesive(black,tacky) in the basement small southwest room contains 10 percent
chrysotile.
■ Caulk(white, hard)around the small window frames in the basement contains 5 percent
chrysotile.
■ Glaze (white, hard)on the large window panes throughout the main floor and second floor
contains 4 percent chrysotile.
■ Glaze (white,thick) on the small window panes in the basement contains 5 percent
chrysotile.
■ Vibration dampener gasket(white,cloth) in the basement associated with the furnace
system contains 70 percent chrysotile.
■ Vermiculite wall insulation in the ceiling and walls contains less than (<) 1�Actinolite
(asbestos)-See Discussion Section
C.i.b. Non-Asbestos-Containing Materials
The following is a summary of building materials found to contain no asbestos or materials that contain
one percent or less asbestos(non-asbestos-containing materials by regulatory definition).
■ Blown-in insulation (brown)with tarpaper layers(black)
■ Braided electrical wiring
■ Brick& mortar
■ Felt paper flooring(black)
■ Light backing(btack)
■ Linoleum flooring(brown/pink/beige, diamond patterned) with black backing
■ Linoleum flooring(gray/white, diamond patterned)with black backing
■ Residual linoleum flooring debris(tan, red specks)
eRAuw
INTERTEC
Pride Construction
Project B1611189
November 30, 2016
Page 3
■ Residual tarpaper(brown)-around small window frames
■ Sheetrock/joint compound
■ Shingles (red, multi-colored, &green layers)
■ Tarpaper(black) -former¤t exterior walls behind siding
Refer to Table I in Appendix A,which lists individual functional spaces of the building,the suspect
materials identified in that functional space,whether the suspect material was identified by analysis to
be an asbestos-containing material, an estimated amount of each suspect material for the functional
space, and includes condition, assessment categories and hazard ratings based on subjective
observations made by our representatives.
Refer to Table II in Appendix B,which lists the homogenous material sample numbers, sample locations,
suspect material descriptions, and the analysis results for each sample.This table summarizes the results
from the Bulk Asbestos Laboratory Report,which is attached in Appendix C.
Bulk asbestos analysis was conducted in accordance with the Environmental Protection Agency's(EPA)
Method 40 CFR, Chapter 1, Part 763,Subpart F, and Appendix A(7/1/87 Edition).
C.2. lead-Based Paint
Lead paint sampling was not conducted as a part of this inspection. However, peeling paint was
observed on the interior walls,windows, doors, and exterior components. According to the Minnesota
Administrative Rules 7035 and 7045, lead-based paint testing is no longer required for demolition debris
disposal. However, untested painted concrete from structures built before 1978 may not be recycled as
fill or aggregate without obtaining a case-specific beneficial use determination from the MPCA. Painted
wood may not be burned and the MPCA strongly discourages the reuse of untested painted lumber.
Any potential lead-based paint-containing demolition waste and/or debris generated during building
renovation or demolition should be subject to proper handling and disposal, consistent with applicable
regulations and requirements.
C.3. Miscellaneous Regulated Waste
A visual inspection for miscellaneous regulated waste materials that require separate handling and
disposal prior to disturbance during building demolition was also performed as part of this assessment.
The following is a list of items documented at the site:
BRauN
I NTE RTEC
Pride Construction
Project 61611189
November 30, 2016
Page 4
C.3.a. Mercury
■ Electrical Systems—electrical paneis, load meters,supply relays,control switches.
■ Heating—natural gas furnace
■ Lighting—fiuorescent lamps
C.3.b. Miscellaneous
Gas Meter
Water Heater
D. Discussion
D.1. Asbestos-Containing Materials
D.1.a. Friable ACM
The following asbestos-containing materials are classified as friable materials according to EPA 40 CFR
Part 61 National Emission Standard for Hazardous Air Poltutants (NESHAPs):
■ 1-3" millboard pipe insulation with tarpaper layers
■ Vermiculite insulation (small grain) -ceiling&wall cavities—See Below
■ Vibration dampener gasket(white, cloth)
Note: Vermiculite insulation was observed in the ceiling and wall cavities. The samples collected of the
vermiculite insulation indicated trace amounts(less than 1%actinolite)of asbestos content.The EPA,
MPCA,and the MDH consider any building material found to contain 1 percent or less asbestos to be a
"non-asbestos containing material." However, due to the "scientific uncertainties associated with
existing testing techniques"the EPA and MPCA recommend assuming that all vermiculite insulation
contains asbestos.This is a developing issue with the regulatory agencies and it is our recommendation
to request a specific interpretation for the site.
The above friable ACMs were observed to be in good condition at the time of our assessment.These
materials should be maintained in good condition to prevent potential exposure to asbestos. Friable
ACMs are to be removed prior to disturbance by demolition in accordance with applicable state and
federal regulations.
eRAUN
INTERTEC
Pride Construction
Project B1611189
November 30, 2016
Page S
D.i.b. Category II Non-Friable ACM
The following asbestos-containing materials are classified as Category II non-friable materials according
to EPA NESHAPs:
■ Adhesive (black,tacky)
■ Caulk(white, hard)-small window frames
• Glaze (white, hard)-large window panes
■ Glaze (white,thick) -small window panes
The above Category II non-friable ACMs were observed to be in good condition at the time of our
assessment. These materials should be maintained in good condition to prevent potential exposure to
asbestos. Category II non-friable ACMs are not considered a hazard unless cut, drilled, sanded, or
otherwise abraded. However, Category II non-friable ACMs that may become friable during demolition
must be removed prior to that activity. In accordance with applicable state and federal regulations.
D.2. Lead-Based Paint
Building components with lead-based paint should be maintained in good condition. If lead-based paint
is to be disturbed during renovation,contractors should follow"Lead Safe Work Practices" and the OSHA
Lead in Construction Standard. If the building were to be demolished in its entirety, building components
with lead paint are not required to be removed or disposed of as lead or hazardous waste. Any lead-
based paint-containing demolition waste and/or debris generated during building renovation or
demolition should be subject to proper handling and disposal, consistent with applicable regulations and
requirements.
D.3. Miscellaneous Regulated Waste
In the case of building renovation/demolition, any of the miscellaneous regulated waste items listed
in Section C.3 that will be disturbed, must be removed prior to disturbance and must be recycled or
disposed of in accordance with state and federal guidelines.
E. Limitations
In any building,the potential exists for hazardous building materials to be located inside walls,above
ceilings, under floors, and other inaccessible areas. Destructive investigation was performed in an
BRauN
INTERTEC
Pride Const�uction
Project B1611189
November 30,2016
Page 6
attempt to locate hazardous materials in inaccessible areas of the building. However, it was not feasible
to inspect 100 percent of these areas.Also,the potential exists for hazardous materials to be found
outside the building buried underground. Braun Intertec cannot be held responsible for the presence of
any such hidden materials. In the case of building demolition, contractors involved in the project should
be made aware of this potential. If previously unidentified suspect hazardous building materials are
exposed during their activities they should be sampled and analyzed for content prior to any disturbance.
Note: A small detached garage is also on the property, but not a part of this inspection.Any additional
suspect building materials from the garage that cannot be cross-referenced to other materiafs in this
report which have already been sampled should be assumed to contain asbestos until proven otherwise
through sampling and analysis.
In performing its services, Braun Intertec used that degree of care and skill ordinarily exercised under
similar circumstances by reputable members of its profession currently practicing in the same locality.
No warranty,express or implied, is made.
F. Asbestos Inspector Certification
,
I,the undersigned,do hereby certify that I am an accredited Asbestos Inspector in the State
of Minnesota. A photocopy of my current asbestos inspector certificate is attached in Appendix D.
,
/ �i'�- .�
Signature: sf�(.:,��-�-r-��_-- Date: I ?� � �2 OI fo
�.
E`ric W.-[3i�Fiiek
Environmental Technician III
Minnesota Department of Health Asbestos Inspector No: AI12781
�
i
1+
jI
I
�
I
1
BRauN
INTERTEC
Appendix A
Table I. Asbestos Building Inspection Results
B � A V N Table I. Asbestos Building Inspection Results
INTERTEC
The Science You Build On.
Client: Pride Construction
Location:3907 Cherry Avenue,Mound,MN 55364
Date of Inspection: November 29,2016
Project:B1611189
Contains Ref.Client
Homogeneous Material Asbestos Sample No. Estimated Quantity Material Hazard
Fundional Space Description (Yes/No) (See Table II) Units Conditionl CategoryZ
Vibretion dampener gasket
Basement (White,cloth) Yes 1 2 gaskets ND 1
Basement Glaze(white,thick)-small yes 2 4 windows 0 3
window panes
Basement Adhesive(black,tacky)-SW yes 3 5 ft2 ND 1
room ceilings
1-3"millboard pipe
Basement insulation with tarpaper Yes 4A-C 20 lin.ft. SD 4
la ers
Caulk(white,hard)-small
Basement Yes 5 5 windows D 3
window frames
Residualtarpaper(brown)-
Basement around small window No 6 5 windows D 0
frames
Residual linoleum flooring
Basement No 7 5 ft� SD 0
debris(tan,red specks)
Main Floor Felt paper flooring(black) No 8 250 ft2 D 0
Linoleum flooring
Main Floor (brown/pink/beige,diamond No 9 300 ft2 ND 0
patterned)with black
backin
Linoleum flooring
Main Floor (gray/white,diamond No 10 50 ft2 ND 0
patterned)with black
backin
Main Floor Light backing(black) No 11 1 light D 0
Main Floor Tarpaper(black)-behind No 12 175 ftZ ND 0
former wood exterior walls
Main Floor Glaze(white,hard)-large Yes 13 9 windows D 3
window panes
Main Floor Sheetrock/joint compound No 14 1,750 ftZ D 0
Vermiculite insulation(small
Main Floor No* 16A-C Throughout ND 0
grain)-wall cavities&debris
Second Floor Glaze(white,hard)-large Yes 13 5 windows D 3
window panes
Second Floor Sheetrock/joint compound No 14 1,250 ft2 ND 0
Table I.Asbestos Building Inspection Results
Table I. Asbestos Building Inspection Results
3907 Cherry Avenue,Mound,MN 55364
B1611189
Page 2
Contains Ref.Client
Homogeneous Material Asbestos Sample No. Estimated Quantity Material Hazard
Functional Space Description (Yes/No) (See Table II) Units Conditionl Category2
Second Floor B�own-in insulation(brown) No 15 450 ftZ ND 0
with tarpaper layers(black)
Vermiculite insulation(small
Second Floor grain)-ceiling&wall No* 16A-C Throughout ND 0
cavities
Exterior Tarpaper(black)-behind No 12 1,250 ft2 ND 0
exterior wood sidin
Exterior Brick&mortar No 17 200 ft� ND 0
Exterior Braided electrical wiring No 19 1 lin.ft. ND 0
Roof Shingles(red,multi-colored, No 18 1,350 ftZ D 0
&green layers)
1. Condition of ACM:
ND=Not Damaged
D=Damaged
5D=Significantly Damaged
2. Hazard Category:
0=No hazard-material does not contain asbestos
1=ACM with potential for damage
2=ACM with potential for significant damage
3=Damaged or significantly damaged asbestos-containing miscellaneous material
4=Damaged or significantly damaged friabie asbestos-containing thermal system insulation
5=Damaged or significantly damaged friable asbestos-containing surfacing material
*Vermiculite insulation was observed in the ceiling and wall cavities. The samptes collected of the vermiculite insulation indicated trace
amounts(less than 1%actinolite)of asbestos content.The EPA,MPCA,and the MDH consider any building material found to contain 1
percent or less asbestos to be a"non-asbestos containing material."However,due to the"scientific uncertainties associated with existing
testing techniques"the EPA and MPCA recommend assuming that all vermiculite insulation contains asbestos.This is a developing issue
with the regulatory agencies and it is our recommendation to request a specific interpretation for the site.
BRA�lN
INTERTEC
Appendix B
Table II. Bulk Asbestos Analytical Results
� ��u N Table II. Bulk Asbestos Analytical Results
I NTE RTEC
The Science You Build On.
Client:Pride Construction
Location:3907 Cherry Avenue,Mound,MN 55364
Date of tnspection:November 29,2016
Project:61611189
Sample No. Sample Location Material Asbestos Content(%)
At Center Vibration dampener gasket(white,
1 Basement Main Space Chrysotile 70
Furnace cloth)
Northeast Glaze(white,thick)-small window
2 Basement Main Space Chrysotile 5
Window panes
3 Basement Lower,West At Ceiling/Walis Adhesive(black,tacky) Chrysotile 10
Room
Insulation: N.D.'
4A Basement Main 5 ace West End At 13"millboard pipe insulation with
P Cefling tarpaper layers Tarpaper 1: Chrysotile 40
Tarpaper 2: Chrysotile 40
Insulation: N.D.
West End At 1-3"millboard pipe insulation with
46 Basement Main Space Ceiling tarpaper layers Tarpaper 1: N.A.'
Tarpaper2: N.A.
Insulation: N.D.
4C easement Main 5 ace West End At 1-3"miliboard pipe insulation with
p Ceiling tarpaperlayers Tarpaperl: N.A.
Tarpaper2: N.A.
Southwest Caulk(white,hard)-small window
5 Basement Main Space Chrysotile 5
Window frames
6 Basement Main Space Northeast Residual tarpaper(brown)-around N.D.
Window small window frames
At Center By Residual linoleum flooring debris(tan,
7 Basement Main Space N.D.
Stairs red specks)
8 Main floor Former Kitchen By Stairwell Felt paper flooring(black) N.D.
By South Floor Linoleum flooring(brown/pink/beige,
9 Main Floor Living Room diamond patterned)with black N.D.
Vent
backin
Linoleum flooring(gray/white,
10 Main Floor South Bathroom By Toilet diamond patterned)with black N.D.
backin
11 Main Floor Living Room At Ceiling Light backing(black) N.D.
Tarpaper(black)-former¤t
12 Main Floor Living Room South Wall N.D.
exterior walis behind siding
13 Main Floor South Bathroom South Window Glaze(white,hard)-large window Chrysotile 4
panes
Table II.8ulk Asbestos Analytical Results
Table II. Bulk Asbestos Analytical Results
3907 Cherry Avenue,Mound,MN 55364
B1611189
Page 2
Sample No. Sample Location Material Asbestos Content(%)
14 Main Floor Living Room South Wa�l Sheetrock/joint compound N.D.
15 Second Floor West Bedroom At Ceiling Blown-in insulation(brown)with N.D.
tarpaper layers(black)
16A Main Floor North Entryway South Wall Vermiculite insulation(small grain)- Actinolite 0.75`
ceiling&wall cavities
Vermiculite insulation(small grain)-
16B Main Floor North Entryway South Wall Actinolite <0.25
ceiling&wall cavities
Vermiculite insulation(small grain)-
16C Main Floor North Entryway South Wall Actinolite <0.25
ceiling&wail cavities
17 Exterior East Side At Chimney Brick&mortar N.D.
18 Roof Second Floor Outside NW Shingles(red,multi-colored,&green N.D.
Window layers)
19 Exterior East Side In Electrical Box Braided electrical wiring N.D.
' Materials containing 1 percent of asbestos or less are not considered to be asbestos-containing materials by the U.S.EPA.
1. Asbestos content is indicated as an approximate percent by area.
2. N.D.=None Detected
3. N.A.=Not Analyzed
4. Vermiculite insulation was observed in the ceiling and wall cavities. The samples collected of the vermiculite insulation indicated trace amounts
(less than 1%actinolite)of asbestos content.The EPA,MPCA,and the MDH consider any building material found to contain 1 percent or less asbestos
to be a"non-asbestos containing material."However,due to the"scientific uncertainties associated with existing testing techniques"the EPA and
MPCA recommend assuming that all vermiculite insulation contains asbestos.This is a developing issue with the regulatory agencies and it is our
recommendation to request a specific interpretation for the site.
gRauN
INTERTEC
Appendix C
Bulk Asbestos Analysis Reports
. EMSL Analytical� �IIC. EMSL Order: 351608314
Customer ID: BRAU50
14375 23rd Avenue North Minneapolis,Mn 55447
Customer PO:
TellFax:(763)449-4922/(763)449-4924
.. http ilwwtiv EMSL.com/minneapolislab@emSLcom Projeet ID:
Attention: Derek Schilling Phone: (952)995-2674
Braun Intertec Fax: (952)995-2020
11001 Hampshire Avenue South Received Date: 11l29/2016 12:30 PM
Bioomington, MN 55438 Analysis Date: 11/30/2016
Collected Date: 11/29/2016
Project: 3907 CHERRY AVE/B1611189
Test Report:Asbestos Ana/ysis of Bulk Materials via EPA 600/R-93/116 Method using Polarized
Light Microscopy
Non-Asbestos Asbestos
Sample Description Appearance %Fibrous %Non�ibrous %Type
1 BASEMENT MAIN Brown/White 25%Cellulose 5%Non-fibrous(Other) 70%Chrysatile
SPACE�CENTER, Fibrous
3516083140001 VIBRATION Homogeneous
DAMPENER
GASKET(WHITE,
CLOTH)
2 BASEMENT MAIN Gray/TanlWhite 95%Non-fibrous(Other) 5%Chrysotile
SPACE NE Non-Fibrous
35160&314-0002 WINDOW,GLAZE Homogeneous
(WHITE,THICK)-
SMALL WINDOW
PANES
3 BASEMENT LOWER, Black 90%Non-fibrous(Other) 10%Chrysotile
WEST SPACE @ Non-Fibrous
351608374-0003 CEILING,ADHESIVE Homogeneous
(BLACK,TACKY)
4A-Insulation BASEMENT MAIN Brown/Gray/Yellow 80%Cellulose 10%Non-fibrous(Other) None Detected
SPACE WEST END, Fibrous 10%Hair
351608314-0004 1-3"MILLBOARD Homogeneous
PIPE INSULATION
WI 2 TARPAPER
LAYERS
4A-Tar Paper 1 BASEMENT MAIN Black 20%Cellulose 40%Non-fibrous(Other) 40%Chrysotile
SPACE WEST END, Fibrous
351608310-0004A 1-3"MILLBOARD Homogeneous
PIPE INSULATION
W/2TARPAPER
LAYERS
4A-Tar Paper 2 BASEMENT MAIN Black 20%Cellulose 40%Non-fibrous(Other) 40%Chrysotile
SPACE WEST END, Fibrous
3stsoa3�4-000ae 13"MILLBOARD Homogeneous
PIPE INSULATION
WI2TARPAPER
LAYERS
4B-Insulation BASEMENT MAIN BrownlGraylYellow 80%Cellulose 10%Non-fibrous(Other) None Detected
SPACE WEST END, Fibrous 10%Hair
351608314-0005 1-3"MILLBOARD Homogeneous
PIPE INSULATION
W/2TARPAPER
LAYERS
4B-Tar Paper 1 BASEMENT MAIN Positive Stop(Not Analyzed)
SPACE WEST END,
3516083140005A 1-3"MILLBOARD
PIPE INSULATION
W/2 TARPAPER
LAYERS
Initial report from:11/30I2016 14:54:45
Printed:11/30/2016 1:54 PM Page 1 of4
. EMSL Analytical� �IIC. EMSL Order: 351608314
Customer ID: BRAU50
14375 23rd Avenue North Minneapolis,M� 55447
Tel/Fax:(763)449-4922/(763)449-4924 Customer PO:
,, hEtp_!lwww.EMSLcum i minneapolislab�c�emsLcom P�OJ@Ct��:
Test Report:Asbestos Analysis of Bulk Materials via EPA 600/R-93/116 Method using Po/arized
Light Microscopy
Non-Asbestos stos
Sample Description Appearance %,Fibrous %,Non-Fibrous %Type
4B-Tar Paper 2 BASEMENT MAIN Positive Stop(Not Analyzed)
SPACE WEST END,
35160831400058 1-3"MILLBOARD
PIPE INSULATION
W/2TARPAPER
LAYERS
4C-Insulation BASEMENT MAIN Brown/Gray/Yellow 80%Cellulose 10%Non-fibrous(Other) None Detected
SPACE WEST END, Fibrous 10%Hair
35160831C-0006 1-3"MILLBOARD Nomogeneous
PIPE INSULATION
WI 2 TARPAPER
LAYERS
4C-Tar Paper 1 BASEMENT MAIN Positive Stop(Not Analyzed)
SPACE WEST END,
351608314-0006A 1-3"MILLBOARD
PIPE INSULATION
W/2TARPAPER
LAYERS
4C-Tar Paper 2 BASEMENT MAtN Positive Stop(Not Analyzed)
SPACE WEST END,
35160831400068 1-3"MILLBOARD
PIPE INSULATION
W/2 TARPAPER
LAYERS
5 BASEMENT MAIN Gray/White 95%Non-fibrous(Other) 5%Chrysotile
SPACE SW Non-Fibrous
351608314-0007 WINDOW,CAULK Homogeneous
(WHITE,HARD)-
SMALL WINDOW
FRAMES
6-Tar Paper BASEMENT MAIN Black 50%Cellulose 50%Non-fibrous(Other) None Detected
SPACE NE Fibrous
35160B3140008 WINDOW, Homogeneous
RESIDUAL
TARPAPER
(BROWN)
6-Brown Mastic BASEMENT MAIN Brown 100%Non-fibrous(Other) None Detected
SPACE NE Non-Fibrous
351608314-0008A WINDOW, Homogeneous
RESIDUAL
TARPAPER
(BROWN)
7 BASEMENT MAIN GraylRed/Black 25%Cellulose 75%Non-fibrous(Other) None Detected
SPACE @ CENTER, Fibrous
351608314-0009 RESIDUAL Heterogeneous
LINOLEUM
FLOORING DEBRIS
(TAN,RED SPECKS)
8 MAIN FLOOR Black 50%Cellulose 50%Non-fibrous(Other) None Detected
FORMER KITCHEN Fibrous
35160831400f0 ON FLOOR,FELT Homogeneous
PAPER(BLACK)
9-Linoleum MAIN FLOOR LIVING Brown/Tan/Black 50%Cellulose 50%Non-fibrous(Other) None Detected
ROOM ON FLOOR, Fibrous
351608314-0011 LINOLEUM Heterogeneous
FLOORING
(BRN/PINK/BEIGE,DI
AMOND PATT.)
W/BLACK BACKING
Initial report from:11I30/2016 14:54:45
Printed:11/30/2016 1:54 PM Page 2 of 4
. EMSL Analytical� �I1C. EMSL Order: 351608314
Customer ID: BRAU50
14375 23rd Avenue North Minneapolis,Mn 55447
Customer PO:
Tel/Fax:(763)449-4922/(763)449-4924
., htip:!%www EMSL com minneapolislab�ivemsLcom Project ID:
Test Report:Asbestos Analysis of Bulk Materials via EPA 600/R-93/116 Method using Po/arized
Light Microscopy
Non-Asbestos Asbestos
Sample Description Appearance %Fibrous %,Non-Fibrous %.Type
9-Mastic MAIN FLOOR LIVING Brown 100%Non-fibrous(Other) None Detected
ROOM ON FLOOR, Non-Fibrous
35�soas�aoo��a LINOLEUM Homogeneous
FLOORING
(BRN/PINK/BEIGE,DI
AMOND PATT.)
W/BLACK BACKING
10-Linoleum MAIN FLOOR Gray/White/Black 25%Cellulose 75%Non-fibrous(Other) None Detected
SOUTH BATHROOM Fibrous
3516083140012 ON FLOOR, Heterogeneous
LINOLEUM
FLOORING
(GRAY/WHITE
DIAMOND PATT.)W/
BLACK BACKING
10-Mastic MAIN F�OOR Brown 100%Non-fibrous(Other) None Detected
SOUTH BATHROOM Non-Fibrous
351608314-OO17A ON FIOOR, Homogeneous
LINOLEUM
FLOORING
(GRAYNVH ITE
DIAMOND PATT.)W/
BLACK BACKING
11 MAIN FLOOR LIVING Black 50%Cellulose 50°/a Non-fibrous(Other) None Detected
ROOM @ CEILING, Fibrous
351608314-0013 LIGHT BACKING Homogeneous
(BLACK)
12 MAIN FLOOR LIVING Black 20%Cellulose 60%Non-fibrous(Other) None Detected
ROOM SOUTH Fibrous 20%Hair
351608314-0014 WALL,TARPAPER Homogeneous
(BLACK)
13 MAIN FLOOR White 96%Non-fibrous(Other) 4%Chrysotile
SOUTH BATHROOM Non-Fibrous
3516083140015 SOUTH WINDOW, Homogeneous
GLAZE(WHITE,
HARD)
14 MAIN FLOOR LIVING Brown/White 10%Cel�ulose 90%Non-fibrous(Other) None Detected
ROOM SOUTH Fibrous
35asoa3�aoo�s WALL,SR/JC Heterogeneous
Sheetrock Only
15-Insulation 2ND FLOOR WEST Brown 100%Cellulose None Detected
BEDROOM @ Fibrous
351608314-0017 CEILING,BLOWN-IN Homogeneous
INSULATION
(BROWN)W/2
TARPAPER LAYERS
(BLACK)
15-Tar Paper 1 2ND FLOOR WEST Black 50°/,Cellulose 50%Non-fibrous(Other) None Detected
BEDROOM @ Fibrous
351608314-0017A CEILING,BLOWN-IN Homogeneous
INSULATION
(BROWN)WI 2
TARPAPER LAYERS
(BLACK)
15-Tar Paper 2 2ND FLOOR WEST Black 50%Cellulose 50%Non-fibrous(Other) None Detected
BEDROOM @ Fibrous
351608314-00178 CEILING,BLOWN-IN Homogeneous
INSULATION
(BROWN)WI 2
TARPAPERLAYERS
(BLACK)
Initial report from:11/30/2016 14:54:45
Printed:11/30f2016 1:54 PM Page 3 of 4
EMSL Analytical� �IIC. EMSL Order: 351608314
Customer ID: BRAU50
14375 23rd Avenue North Minneapolis,Mn 55447
Tel/Fax:(763)449-4922/(763)449-4924 Customer PO:
.. http:!Iwww.EMSLcom!mmneapolislabplemsl con� PfOJeCt��:
Test Report:Asbestos Analysis of Bulk Materials via EPA 600/R-93/116 Method using Polarized
Light Microscopy
Non-Asbestos bestos
Sample Description Appearance %Fibrous %Non-Fibrous %Type
16A MAIN FLOOR Brown/Tan 98%Vermiculite <1%Actinolite
NORTH ENTRYWAY Non-Fibrous 2%Non-fibrous(Other)
3516083140018 SOUTH WALL, Homogeneous
VERMICULITE
INSULATION
16B MAIN FLOOR Brown/Tan 98%Vermiculite <i%Actinolite
NORTH ENTRYWAY Non-Fibrous 2%Non-fibrous(Other)
351608314-0019 SOUTH WALL, Homogeneous
VERMICULITE
INSULATION
16C MAIN f�00R BrownlTan 98%Vermiculite <1%Actinolite
NORTH ENTRYWAY Non-Fibrous 2%Non-fibrous(Other)
351608314-0020 SOUTH WALL, Homogeneous
VERMICULITE
INSULATION
17-Brick EXTERIOR EAST Red 100%Non-fibrous(Other) None Detected
SIDE @ CHIMNEY, Non-Fibrous
3516083140021 BRICK&MORTAR Homogeneous
17-Mortar EXTERIOR EAST Gray 100%Non-fibrous(Other) None Detected
SIDE @ CHIMNEY, Non-Fibrous
351608314-0021A BRICK 8 MORTAR Homoge�eous
1 S-Red Shingle ROOF 2ND FLOOR Red/Black 25%Cellulose 75%Non-fibrous(Other) None Detected
OUTSIDE WINDOW, Fibrous
357608314-0022 SHINGLES(3 Heterogeneous
LAYERS-RED,
MULTI-C.,GRN.)
1 S-Multi-Colored ROOF 2ND FLOOR Black/Blue/Green 25%Cellulose 75%Non-fibrous(Other) None Detected
Shingle OUTSIDE WINDOW, Fibrous
SHINGLES(3 Heterogeneous
351608314-0022A LAYERS-RED,
MULTI-C.,GRN.)
18-Green Shingle ROOF 2ND FLOOR Black/Green 25%Cellulose 5%Mica None Detected
OUTSIDE WINDOW, Fibrous 70%Non-fibrous(Other)
35160831<-0022B SHINGLES(3 Heterogeneous
LAYERS-RED,
MULTI-C.,GRN.)
19 EXTERIOR EAST Tan/Black 95%Cellulose 5°/a Non-fibrous(Other) None Detected
SIDE @ ELEC.BOX, Fibrous
351608314-0023 ELECTRICAL Homogeneous
6RAIDED WIRING
Analyst(s) �- �
Nicholas Asuncion(33) Rachel Travis,Laboratory Manager
or OtherApproved Signatory
EMSL maintains liability limited to cost of analysis. This report relates only to the samples reported and may not be reproduced,except in full,without written approval by EMSL. EMSL bears no
respo�sibility for sample colledion adivities or analytical method limitations. Inierpretation and use of test results are the responsibiliry of the client. This report must not be used by the client to claim
product certification,approvai,or endorsement by NVLAP,NIST or any agency of the federal government. Non-friable organically bound materials present a problem matrix and therefore EMSL
recommends gravimetric reduction prior to analysis. Samples received in good condition unless otherwise noted. Estimated accuracy,precision and uncertainty data available upon request.Unless
requested by the client,building materials manufactured with multiple layers(i,e.linoleum,wallboard,etc.)are reported as a single sample.Reporting limit is 1%
Samples analyzed by EMSL Analytical,Inc.Minneapolis,Mn NVLAP Lab Code 20001&0
Initial report from:11I30/2016 14:54:45
Printed:11l30/2016 1:54 PM Page 4 of 4
' EMSL Order: 351608314
EMSL Analytical, Inc. Customer ID: BRAU50
14375 23rd Avenue North Minneapolis,Mn 55447 Customer PO:
Phone/Fax:(763)449-4922/(763)449-4924 Project ID:
M h�tp��www.EMSLcom/minneapolislab@emsLcom
Attention: Derek Schilling Phone: (952)995-2674
Braun Intertec Fax: (952)995-2020
11001 Hampshire Avenue South Received: 11/29/2016 12:30 PM
Bloomington, MN 55438 Analysis Date: 11/30/2016
Collected: 11/29/2016
Project: 3907 CHERRYAVE/61611189
Test Report: Asbestos Analysis of Bulk Materials by PLM via EPA 600/R-93/116 Method
using Polarized Light Microscopy. Quantitation using 400 Point Count Procedure
Non-Asbestos Asbestos
Sample Description Appearance %Fibrous %Non-Fibrous °/.Type
16A MAIN FLOOR NORTH Brown/Tan 9925%Non-fibrous(Other) 0.75%Actinolite
351608314-0018 ENTRYWAY SOUTH Non-Fibrous
WALL,VERMICULITE
INSULATION Homogeneous
16B MAIN FLOOR NORTH BrownlTan 100°/Non-fibrous(Other) <0.25%aActinolite
351608314-0o1s ENTRYWAY SOUTH Non-Fibrous
WALL,VERMICULITE
INSULATION Homogeneous
16C MAIN FLOOR NORTH Brown/Tan 100%Non-fibrous(Other) <0.25�oActinolite
351608314-0020 ENTRYWAY SOUTH Non-Fibrous
WALL,VERMICULITE
INSULATION Homogeneous
Anatyst(s) �-- `'�`
Nicholas Asuncion(3) Rachel Travis,Laboratory Manager
or other approved signatory
Disclaimer:Some samples may contain asbestos fibers present in dimensions below PLM resolution limits.The limit of detection as stated in the method is 025%. EMSL Analytical Inc suggests that
samples reported as<0.25%or none detected undergo additional analysis via TEM. The above test report relates only to the items tested. This report may not be reproduced,except in full,without
written approval of EMSL Analytical Inc.This test report must not be used by the client to daim produd endorsement by NVLAP or any agency of the United States Govemment. EMSL Matytical Inc.,
bears no responsibility for sample co�lection activitles,analytical method limitations,or the accuracy of resutts when requested to separate layered samples. EMSL Analytical Inc.,Iiability is limited to
the cost of sample analysis.The test resul[s wntained within this report meet the requirements of NELAC unless otherwise noled.Samples received in good condition unless otherwise noted.Unless
requested by the client,building materials manufactured with multiple layers(i.e.lindeum,wallboard,etc.)are reported as a single sample.
Samples analyzed by EMSLAnalylical,Inc.Minneapdis,Mn
Initial report from:11/30I2016 14:54:50
Printed 11/30/2016 1:54:51PM Page 1 of 1
Appendix D
Asbestos Inspector Certificate
, .� � i
� , � � �l ,► .► �
c�n�nad��ay: '
�/ � � .,. State of Minnesota �
` � �t7? � t1� � '-�� Expires�r11/08/2tf��7s � (� �J � '� �
D ��� � 2D081J Be�A e � a (
`/ ,•, � St Paul,MN 55106 �
� � ,.� ;� `�
� N 6irector,'�nv. Health Div. No AI12781 Issued 11/16/2016 �, "'� a �
�
� � � J
� � � I
D � � ' o `;� Q I
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�' � � � � °' � � .� �
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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 4 4 3 0 4
Counry Name
WELL AND BORING SEALING RECORD Minneso a�Unique Well No.
Minnesota Statutes,Cha ter 1037 or W-series No.
P (Leave blank il nol known)
ti
Township r�e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
+^rc��cs 117 ?� r?r -�;� 9g �.: 2.
GPS LOCATION-decimal degrees(to four decimal places) (� /
Depth Before Sealing V� ft. Original Depth ft.
Latitude Longitude
IFER(S) STATIC WATER LEVEL
Nu or Boring Location Single Aquifer ❑Multiaquifer �,/
yYEyLiBORING �Measured ❑Estimated Date Measured,���l
�'��" f'-�-��^ - - " '�vater-Supply Well ❑Monit.Well /
Show exact location of v/ell or borin Sketch ap of well or boring
in section grid with"X." locatio ,showing property ❑Ern.Bore Hole ��Other �ft. I,�below ❑above land surface
line oads,and buildings. CASINGTYPE(S)
. ..1 i . _ -..
� � � � , � ,', �.
--'----i- --`-- ---'-- ' �,/
„J ; IYSteel ❑Plastic ❑Tile ❑Other
7\
--'--- --i--- ---h-- ---t-- f WELLHEAD COMPLETION
� � , � .�._�_.
W ; : ; : ET �,/
� � � � Outside: ❑Well House ❑At Grade Inside: IR Basement Oftset
--;--- --�----%-- --%-- �'-
; ; ; , 'h nniie � ❑Pitless AdapteUUni[ ❑ uned Well Pit
B ' �
--�--- --�-----�----�-- s J ❑Buried �
1 �� ❑Well Pit
S ❑Other
�i M;ie� ❑Other
PROPERTY OWNEA'S NAME/COMPANY NAME CASING(S)
��lr�.i' ��:�7V�:�2.bl ' Diameter / Depth / Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if ditte�ent ihan well location address indicated above ��
�in.from � to ft. ❑Yes �Jo ❑Yes ❑No ❑Unknown
���v ;��$t N111. n� in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
(,TFIteCtOWlI� 1''�? )rj'�t,t�
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
� f
Well owner's mailing address if diflerent than property owner's address indicated above Sc�een from__�_to�ft. Open Hole ffom to ft.
OBSTRUCTIONS
�Rods/Drop Pipe �]Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)�I�w�JC �� �" V�j
GEOLOGICAL MATERIAL COLOR HARONESS OR FROM TO Obstructions removed? s � i No Describe
FORMATION
PUMP
I(not known,indicate estimated formation log from nearby well or boring.
Type
'� ❑Removed �Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�Jo 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_,__
VARIANCE
� Was a variance granted from the MDH for this well? �_;Yes � No TN#
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material N��.���from C,G'' to_�'ft. yards a• 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 properry? ❑Yes [�lo How many?
LICENSED OR REGISTERED 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.
�n `�tc�-lola ��eli F�ri 11 i*� ('p� In� ��1
Licensee Business Name f License or Regishation No.
�; �,if 11-3�J—lh
�'fied Representa ve Signature Certified Rep.No. Date
" 3 4 4 3 0 4 `Ti� ��t"�,g��
LOCAL COPY Name of Person Sealing Well or Boring
HE-01434-14 ID#53159 5/13R
.. . . . . . . . . .. . .. . :..... ... .._. ... .�.. _ . . ._._.. . . . . ... _. . . . . .. . __.: