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<br />1t.l.rt ~I ~ <br /> <br />WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 125365 <br /> WELL AND BORING SEALING RECORD Sealing No. <br />WtSEY Minnesota Unique No. <br /> Minnesota Statutes. Chapter 103/ or W-series No. <br /> (Leave blank if not known) <br /> ,...., )Dw'2h; No.123ge No. action fffra~E (Splg~ Date Sealed Date Well or Boring Constructed <br /> AUG 22, 1997 1950's <br />Numerical Street Address or Fire Number and City of Well or Boring Location 170 ? <br /> 2417 II CLBYBLARD Depth Before Sealing ft. Original Depth ft. <br />Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br />in section grid with 'X'. N location, showing property i"~ingle Aquifer D Multiaquifer <br /> iines, roads, an "ildings. <br /> N WElUBORING ~easured D Estimated <br /> , , , , "'!. Water Supply Well D Monit. Well <br /> -.,...- , , , I 40 <br /> -.,...- -T- --,-- ft. JDbelow <br /> o Env. Bore Hole 0 Other o above land surface <br /> , , , jE Q -.,...... e... <br />W -T- -T- -T- CASING TYPE(S) <br /> , , -i-- n+_ T ,1 ~. 10 Steel <br /> , , D Plastic D Tile <br /> -T- -T- 5~'i D Other <br /> ~m;Je ~. <br /> , -t- -+- ..-+- 1 " ~- CASING <br /> --:-- <br /> ~\ Diageter 0 Depth130 Set in oversize hole? Annualar space initially grouted? <br /> S <br /> ~lmHe--+ _ in. from____ to_ ft. DYes I- No DYes D No D Unknown <br />ffWTYOFEitillvILLE _ in. from_ to_ ft. DYes D No DYes D No D Unknown <br />Property owner's mailing addn:tSS if different than well location address indicated above. _ in. from_ to_ft. DYes D No DYes D No D Unknown <br />~ITY HALL CO aD C SCREEN/OPEN HOLE <br />ItOSEVILLE , - 55113 130 170 <br /> Screen from to ft. Open Hole from to ft. <br />~TTII : DBRIfIS WALSH OBSTRUCTlONlDEBRISlFILL <br />~ER'SNAME ~ Obstruction D Debris D Fill D No pbstruction to ~~~~. <br />Well owne(s mailing address if different than property owne(s address indicated above. Type of Obstruction/Debris/Fill _b\yt "" pA14s <br /> ObstructionlDebrislFiII remOVed?)DJ Yes D No <br /> PUMP <br /> Type UIIIQUfR <br />GEOl~LMATERU~ COLOR HARDNESS OF FROM TO D Removed '/1 Not Present D Other <br /> FORMATION <br />" not known, i_ estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: <br />!OCKY CLAY BROWK/ ;RAY 0 36 ~ No Annular Space Exits <br /> D Annular space grouted with tremie pipe <br />:LAY BROIIR 36 65 D Casing PerforationlRemoval <br />:;AlII) BROtIR 65 97 in. from to ft. D Perforated D Removed <br /> CleAT 97 117 in. from to ft. D Perforated D Removed <br />:;AlII) BR018f 117 122 Type of perforator <br />In....,.. v GREEN 122 !37 <br /> D Other <br />~...... - LIlli' GR ,,"Y 137 !49 GROUTING MATERIAL(S) <br /> I. <br />LoIIIES'fORE GRAY 149 !71 POR'1'LAItD 170 SURF 58 <br /> Grouting Material from_ to_ ft. _ yards_ bags <br /> from_ to_ ft. _ yards _ bags <br /> from_ to_ ft. _ yards _ bags <br /> from_ to _ ft. _ yards _ bags <br />REMARKS, SOURCE OF tlATA, DIFFICULTIES IN SEALING UNSEALED WEllS AND BORINGS <br />2.OLOGY l'RCII : 2121 IRfY 136 Other unsealed well or boring on property? D Yes ~ No <br />ilA'l'BR LBVEI. DI ABOVE WELL: 110' liCENSED OR REGISTERED CONTRACTOR CERTIFICATION <br />MTB WA'l'BR LEVEL TAKER: 02-11-59 This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The infannallon contained in this report is <br />[1-1 7 true to the best 01 my knowledge. <br /> E.H. ~ It SOlIS, IRe. 71015 <br /> SEALED Cont ;d;:' ~~ ~. License or Registrerion No. <br /> 9/2/97 <br /> . <br />According to MN State Regulations Authorized Represe'tatfve Signature Date <br /> KEYIII SCHBITBRLEIR/KEVDI HOPPE <br />IMPORTANT -FILE WITH PROPERTY IH 125365 Name of Person Sealing We/lor Boring <br />PAPERS-WELL OWNER COPY <br /> <br />HE.Q1434.Q2 <br /> <br />101115R <br />