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Well Sealing Doc
tM1 iN� �A EP 1 f 1 NT OF'H J#�TN ' a ; rtneaota Y e118r f6At9ng 7 - W6LLOR.6DI11NC3:lt5CATIgN SeBlirr$No H a { WLR, AND SORING 51�#NG RECODa RA)nriesota u County Name riigua UVelk Ntt t` lvlrnnesota Statutes Chapter fU•3T '1.'•:',1,-.-','!;:':'':',..4:- ..',.'::: ordes Nn A A'OVp _ - ;6.-r.*::$6,amtto>am) Ain iV1 Township Name Tgwnshlp No. Range Np. 49ian No F odorl(am'1•.'.7.,`,,:17'I ) tate$wiled Data Wel)or BprFng Constructe•d I RIDLEY 30 24 13 $W Sid 1 Mk Ffddey,Apn113,2012 r ''.1',0:0••';',.'../, ''.::::',.:,!.• -a L-: n ,- J 7 e r ' } h L t l ey nvrr„, k J y r1)t T t'Y f ?� M a.; 1 p :fir t' 7 •GPS Lati da t�49m 'r' P . . ae 7+7>9 1Yg kt E3efare$ealin_ { *,tX Qdglrial 1t LOCATION' I angiwda ' degrees ,-, ',.,,, rNniites "saconde AtM11trER(s) STATIC WATER LEYE4 Numerlcsi.StreetAddress or Fire Number and City of Wali of Boring Locatlon Al t3utgieAL�uifet D Mud••aquifer 67'5'CHANNEL'ROAD,NE,FRIDLE`li.',55432 WEkuBORING .. L ,t�teaeurett d sumated Date Measured 04N3112 ' , �SNe1er-Supply Well U Monit Wilt Show exact bcatton s#watt ar•boring 3kefeh• map of well of boring 26 ,,,,s,,!!,.cn gi?d Iotatlon,straw.r�prapady D Eritc 6ota ttaa , C '�fiite� tt below ©Bbova land surface u lines,roads,aria lldings ,.. N '� � � oy;,,,;,,,,...,,,,..,-,.:,,,,,„..7,:,,,,,,,,, �"atG4T u)�ktlgsill)'c[�TiIQ �,C?ttier "'II r' "1 J k tC } *k t ; r'& WELLHEAD COMPLETION , itafue QtrtsMe:.fl Well House Ai riOd-. Itistda 6 Basement Offset b MOa [ Pities Adaptor/(Unit .. Buried Wali Pk F.' _.I-_ 0 Burled ,�� e � t � e I PIi ; • {QW 1 ;, � � P� f ; ..,� ,4:-1;::4-,:-.7 ., 5 i?thar� r r , y _s.x a,<.r ,sr+*� • 5 - } ” , ' •PEF7TY;C)WN '$ ff COMPAi Y NAME a 'I'iASt('tE3($? 1 JONES.JUDIT'1-I Diameter „ ' pe¢t7,„..,,,,-..."..••,'..'........,..,!..,..f..! r at k t, r�t a hd e? Ao�fuiar span'Inldally grouted? f i Property owner a mma g ft5fdr If mnereht frau weu,oc ton address Indicated above : from ,, to tt r }Yes iXNo ©Ye9 D No ,D Upimawri 6735 CHANNEL:nAl3 NE • FRIDLEY MN 5 S fn frort�___ to It- ( D Yes'''-:-.,;-: -.;...C:1-!! ..:'...---.oD Yes D No D Unknown 'kn from is ft D Yea'' No,:,:_.". ..--„:"-J.::.--:•-••:,:'!":.,-,.--• (_}Yes •Cf I+ro D unknown F'.'-j,...WOWNER $A tE/coMPANY;NAME SCR NIgPEN w•oke v AL • Well oyrrulr a mating addr f dfaarent than proper)y owner a a•gdrass indieaa@d kaofe scr•eis ftgnt to tt t n+faka frorki, ,'ko I' SAME ` � oBSTed�trls>as � `: ` Rodd/.?rep Pips D Chaok vatvets r • ( Debris C F1tl NoQbetruction z , emoved 54,X,1 25 rap Pim'B Jet Palter.... ., ,. it yPa fObsri'u a (t)escribe)` GEOLOGICAL MAtERIIAL COLOR HAIiANE85 DR FROM:-.[,,,,....70..„.,...-...LObstruettons removed? I Yes U No Describe •:..,..„0,440.,071,, v s � ., � f�RtiIAT(tt91 � ,. l if not known,k dlcata eked forrhatlon lob from nearby wett;tr bofrng PU�AP Ty, i3eeE�'�leli,Jet Pump#42 Gallon T0nk I G hEQLOG'iY F ROiVII 673$'.CHANNE R O/L1 NE y'�Iy. + t pb L 4 I :�r {, •,1� * 1 hT-^"^ V h 1:' � aWcI T,C' +.: �'`' 'Y 'M 'Pit Q ,METHOD;USED TO•SEAL ANNULAR!PACE BFTWEEN?t CASINGS OR CASING AND BORE I OLE ,. Sand • <" 5 ..,.'(0 Annular space Exiets: }Annt teSpace touted wiin7remie Pipe N O Caefng Perforaltori/Removat • iri frgm to' []Perforated {Removed ,' Cla Yellow 1 ?r U �! •� 'rte In from to 9k �]Perforated D Removed Clay Blue 20 75 f'r � s 15 64 Type of Perforator , a r t y tax s �' ,,J } + A - 'P�, ' —r ' Static Water. ,31` GROD1)49;!# ..;•:•••• ,•,,...':•,--,',',.;.' 1A MA'TERIAL.(S) (One b ag of cement o t14 Ibs.r on@ hag of•ae pnite.5 50 Ib2)- n '';�Grouting M serial ,:Neat•Cement from 8 6:5-, ft o t 1....--.:•--•i'-':''''•-:••,::._:.bags ; Screen=2 Redhead + , .,� Erivlropltig from 6 5 to 84 26 4425 ns f r Y 9 frartt to it 0 @nsf bags 1 ' r' { , ER'WEG.1 D NOpfNGS”. a ,/ �i ', R tree .•500 EO Dili!^! bI FtouLT1E3INSEAUAtt '- � '� 1, ; k Qthar t.o.r.ted and unused wall i}r boring•ten propert P`' { Yoe ;Hgw many? • Well Located In l uinp Roon On West Side t'3f Ba8Bf't'tent �Ep'OS REGISTERED CONTRACYC)If•CER•TIFjCATION '.1 ThisYrett orlaonrig Was sealed ht a rdance with Minnesota Raie9 Chapter 4723 The tnihrmattgn•contained in this report l'-:----:-.'''.1');.:1 Wel(Depth Measured From Grade Level is t -ta:h?e►est,..i-,,f...,my knower �, M D.H.Inspector Wa Not On Site DWIn9 Sealing M�iiott L. Malenke/M K8Wdate {763)493 3550 1426,A. r' Receives Well Sealing htotillc atlotl'From MMD H t eery aualnass Name • L/censariTe$tstrakon Na ''z w a " / t a !.' M' L Male ice "347 A• + AApril13:2k31 j Pl O~ 13 24' 21 O�07 neap,,,:e g krPa - + tlrkttad-Rep No Date, t 30119 •• • y Name of Persdn 5edllfrg We/l or ijE-01434-12: IO#f 40.0423 • s pga: r a; 'i ._ �...__._._. .� ...�.,..,�.z.iis� _A.;....f.�a,9.�::'_��.J2,v.......r.,.5.,,,,,,,,,,,...,,,:,-,: ,:„......;:,....2,.,,...,,,,,...... ...._ t .�,.._.