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<br />. 4.;,.- ~ <br /> <br />'-=-or-'r'"~ <br /> <br />-. <br /> <br />WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring IH 185186 <br /> WELL AND BORING SEALING RECORD Sealing No. <br />County Name Minnesota Unique Well No. r <br /> , ~ <br />RAMSEY Minnesota Statutes, Chapter 103/ or W-series No. <br /> - jl.eDYe> I:JIarm If noIknown) <br />ROSEmLE I T;nShIP No 123nge No Section No. ~on Ism... Ig.1 Date Sealed Date Well or 80ring Constructed <br />15, SW",NE,. NOVEMBER 12.2011 UNKNOWN <br />Numerical Street Mdress or Fire Number and City of Well or BOling Locafion <br />2018 HAMLlNE AVENUE N Depth Before Sealin.g 110 ft. Origmal Depth ,/, h. <br />Show exact location 01 .....ell Or boring Sketch map of well or bonng AQUIFER(S) STATIC WI>.TER LEVEL <br />in sectiQn grid with ~X"_ N location, showing property }( Smgle Aquifer o Multlaqulfer <br /> lines, toad~, and buildings. WELUBORING ~ Measured o Estimated <br /> N <br /> , , ~ Water Supply Well o Mon!\. Well <br /> -t- ''-' -t~ --,-- o Other__ , below <br /> , ~.~ o Env. Bote Hole 7S' ft o above land surface <br />W -T- -T- ~- --1-- E Y CASING TYPE(S) <br /> . T t: <br /> , -t~ , ul" .- ~Steel o Plastic 0 Tile o Other <br /> --;- -:-- - <br /> ~mile <br /> -t- -+- -+- -'lU 1 D f CASlNG(S) <br /> ~ DIameter 2" 0 Deplh Set in oversize hole? Annular space initially groute, <br /> -:I lOT <br /> s OVes ~ No o Ves ONo o Unkr <br /> f-- f m..-------+ _ in. from_ to_ ft <br />CFffBji~Sh~ _ in_from_ to_ft o Ves o No DYes o No DUnk' <br /> e' an wen location addre$s indicated above_ in./rom_ to_ft. o Yes o No o Yes oNo DUnk, <br />2600 CIVIC CENTER DRIVE SCREEN/OPEN HOLE <br /> 107 110 Open Hole from <br />ROSEVILLE, MN 55113 Screen from to H. to H, <br /> OBSTRUCTIONS <br />~NER'SNAME o Rods/Drop Pipe o Check Valve(s) o Debris 0 Fill ~ No Obstruction <br />WeU owner'-s mailing address if different than property owner's address indicated above. Type of Obstructions (Describe) <br /> Obstructions removed? 0 Ves ONo Describe <br /> - - PUMP JET PUMP <br /> Type <br />GEOLOGICAL III. TERL\L CO~OR HARDNESS OF FROM TO ~ Removed o Not Present o Other <br /> FORMATION METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS. OR CASING AND BORE HOLE: <br />"not known, indicate estimated fotmation log from nearby weU or boring.. <br /> ; No Annular Space Exists .,. <br />f"LAY ?7 o Annular space grouted with trernie pipe ~ <br /> o Casing PerforationIRemoval <br /> ;1 1&" in, from to ft, o Perforated o Remove- <br /> . <br />LIMESI'ONE GRAY 79 211 in. trom to ft. o Perforated o Rem<>K <br /> Type of perforator <br /> 0 Other <br /> GROUTING MATERIAL(S) (One bag of cement = 94 Ibs.. one bag of bentonite = 50 Ibs.) <br /> PORTLAND 110 0 3 <br /> Grouting Material from - to_ ft, _ yards_ <br /> from - to_ ft, _ yards_ <br /> from_ to_ H, _ yards _ <br /> from _ to __ ft, _ yaros _ <br />REMARKS, SOURCE OF DATA. DIFFICULTIES IN SEAUNG OTHER WELLS AND BORINGS <br />REMARKS: Other unsealed and unused well or boring on property? o Ves }lJ No How many? <br />GEOLOGY FROM: 1600 Block &. Mid Oaks Ln, RV LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br />WATER LBVEL IN ABOVE WELL: 135" JniS welt or boring was sealed in eccordance with Minnesota Rules, ChaPter 4725, The Information contained I <br />DATE WATER LEVEL TAKEN: 01/29/59 tlUe to the best of my knowledga, <br />MAPCOD~t:ALE D E. H. RENNER &. SONS, INC. 71015 <br /> Contracfor BusiOf/SS Nsme L_ or RBgistralWn <br />According to MN State Regulations _~"'M-", November 19, 2 <br /> Dale <br /> KEVIN HOPPE I KEVIN SCHEITERLEIN <br />IMPORTANT-FILE WITH PROPE1H 185186 Name of Person Sealing Welt or Boring <br />PAPERS-WELl OWNER COPY <br /> <br />\-- --- <br /> <br />~ <br />\- <br /> <br />