WELL AND BORING SEALING RECORD WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H
County Name WELL AND BORING SEALING RECORD Sealing No. 3 0 9 6 8 6
Minnesota Unique Well No,
AnokaMinnesota Statutes,Chapter 1031 or W-series No.
(festa..Y rot k.=en]
Township Name Township No, Range No.Section No. Fraction(sm.—.Ig.) Date Sealed Date Well or Boring Constructed
Frey 13 124 14 I S SW NE '3-r_ t'S
GPS Latitude degrees_ minutes_ seconds Depth Before Sealing 72 ft. Original Depth ft.
LOCATION: Longitude._ degrees_ minutes seconds
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location X)Single Aquifer 0 Multiaquifer
522 66th Ave NE, Fridley 55432 WELL/BORING 11j Measured 0 Estimated Date Measured a_$-13
Show exact location of well or boringIt`I Water-Supply Well 0 Montt,Well
in section grid with"X." Sketch map of well or boring
I N �� cation,sl� property 0 Env.Bore Hole 0 Other ft ( below 0 above land surface
s,r a b l ' s.
CASING TYPE(S)
y — ut 1 ]Steel 0 Plastic 0 Tile 0 Other t
---'-----+--,-- a
----- WELLHEAD COMPLETION
w i E v
.' l. :--- T Outside: 0 Well House 0 At Grade Inside: ]Basement Offset
111
'k MII 0 Pitless Adapter/Unit 0 Buried 0 Well Pit
•
S ❑Well PR 0 Buried
1---1 Mile—H ❑Other ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Marilyn Si11Ivan Diameter '
Property owner's mailing address if different than well location address indicated above Depth Set in oversize hole? Annular space initially grouted?
ia:,from 0 to ft, D Yes r]No 0 Yes 0 No 0 Unknown
in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown
. in,from to ft. 0 Yes 0 No 0 yes 0 No 0 Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN'HjOLE -�P y
Well owner's mailing address if different than property owner's address indicated above Screen from �y _to { €J ft. Open Hole from .to .ft
OBSTRUCTIONS
J Rods/Drop Pipe 0 Check Valv(*) 0 Debris 0 Fill
] �.p 0 No Obstruction
Type of Obstructions(Describe) �t6''d� I)I 1147
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 1
FORMATION ®Yes 0 No Describe
If not known,indicate estimated formation I 09 from nearby well or boringPUMP
bor
ring._ R
' zi -115 T e pt
Removed 0 Not Present 0 Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
p No Annular Space Exists 0 Annular Space Grouted with Tremie Pipe 0 Casing Perforation/Removal
in.from to ft.
0 Perforated 0 Removed
in.from to ft.
0 Perforated 0 Removed
Type of Perforator
0 •
Other . .
GROUTING MATERIALS) (One bag of cement.94 lbs.,one bag of bentonite=50 lbs.)
Grouting Material ileci r t f,•►..{t'IT from_Q___to 7lf ft. yards r, 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 0 Yes EF No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION —
This well or boring was sealed in accordanie with Minnesota Rules,Chapter 4725.The information contained in this report
is true to the best of my knowledge.
Don Stodola. Hqell Drilling co., Inc. 1691
Licensee Business N e ...e" License or Registration No.
. .. sentative Signaft /� Certified Rep.No. Date
—^^
IMPORTANT-FILE WITH PROPERTY H ''J_)6 8 6 / J
PAPERS-WELL OWNER COPYName of Person Sealing Well or Boring
uC n441o.1.., .......