2015 WELL SEALING 04.08This is a Well and Boring Sealing Record for the attached property.
It is important that this record is kept with any paperwork for this
property. In the future, the homeowner may need information about
the sealing of their well. This record has been sent to the state, the
homeowner, and this copy is for the local city/township. Please
deliver to the correct department.
Thank You,
Kelsey Duresky
E.H. Renner & Sons, Inc. 763-427-6100
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL OR BORING LOCATION H 328148
Sealing No.
WELL AND BORING SEALING RECORD
County Name Minnesota Unique Well No.
Minnesota Statutes, Chapter 1031 orW_serJosNo
4— blank k R M�)
Anoka
Township Name
Township No.Range
No.
Section No.
-+Fraction (am, Ig.)
Date Sealed
Date Well or Boring Constructed
Fridley
30 ,j
24
13
lNe SONW
04/07/2015
Unknown
from tc�_ ft. E] Yes E] No E] Yes E] No 0 Unknown
GPS LOCATION — decimal degrees {to four decimal places)
98
98
%'Depth
'
Latitude 45 0520.10N Longitude 93 94'20.57
Before Sealing ft.
Original Depth
WELL OWNER'S NAME/COMPANY NAME
SCREEWOPEN HOLE
AqUIFER(S)
Z Single Aquifer E] Muitiaquifer
STATIC WATER LEVEL
04/07/15
/Measured [] Estimated Date Measured
Numerical Street Address or Fire Number and City of Well or Boring Location
ELL/BORING
Well d5R=lIng address If different than property owners address indicated above
6651 Channel Rd NE, Fridley .
OBSTRUCTIONS
Water -Supply Well El Monit. Well
/
20
Show exact location of well or boring
in section grid with "X"
Sketch map of well or boring
location, showing
L] Env. Bare Hole [] Other
slow El above land surface
A
GEOLOGICAL MATERIAL
N
lines, roads, anKuriolglegrtsl,
CASING TYPE(S)
TO
I
ML M
MEMO
MEMS
_j
fj Steel E Plastic E] rile E] Other
WELLHEAD COMPLETION
E TOutside: F1 Well House 0 At Grade Inside: /Basement Offset
Mile Pftless Adapter/Unit L] Buried El Well Pit
4PX� [-] Ak F-1 Well Pit 0 Buried
3
E] Other
1 Mile
N
❑ Other
PROPERTY OWNER'S NAME/COMPANY NAME
CASING(S)
IRit�s
-hi'allfig 4.U.4
Dlamejr Depth Set in oversize hole? Annular space Initially grouted?
5 93
Prop a owners di flarent than well location address indicated above
In. from tQift. E] Yes / No ❑ Yes / No [] Unknown
6651 Channel Road NE
from tc�_ ft. E] Yes E] No E] Yes E] No 0 Unknown
Fridley, MN 55432
in. from to ft. ❑Yes [:1 No F] Yes Ej No F] Unknown
WELL OWNER'S NAME/COMPANY NAME
SCREEWOPEN HOLE
93 98
Well d5R=lIng address If different than property owners address indicated above
Screen from to ft. Open Hole from t0 ft.
OBSTRUCTIONS
/ Rods/Drop Pipe El Check Velve(s) E Debris El Fill El No Obstruction
Type of Obstructions (Describe)
GEOLOGICAL MATERIAL
COLOR
I
I HARDNESS OR
FORMAMON I
FROM
TO
I
Obstructions removed? Yes E] No Describe
Z
If not known, indicate estimated formation log from nearby well or boring.
PUMP
Jet PUMP
Type
Sand Mown
-3-2-
Removed [I Not Present F1 Other
/
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
G
Cl ay ray
1 No Annular Space Exists ❑ Annular Space Grouted with Tremle Pipe El Casing Perforation/Removal
I in. from to ft. El Perforated ❑ Removed
Gravel Brown.
in. from to ft. Ej Perforated 0 Removed
Type of Perforator
VARIANCE
ZWas
a variance granted from the MDH for this well? E] Yes /No TN#_
GROUTING MATERIAL(S) (One bag of cement= 94 lbs., one bag of bentonite = 50 lbs.)
Acca j;:10 tn 1 Q#A4.
UVI UU WMAW&
Neat Cement 5 93 5.5
Grouting Material from to ft._ yards 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 property? [-I Yes No 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.
Geology from1315 66thAve, Fridley
E,H. Renner & Sons, Inc. - 1431
Water level in above well: 65ft
.
Licensee Business Name License o04
Date water level taken: 04/26/1983
08%15
well log from close by
t��__Iified
property
Unique #'A-7_1 83
Certified Representath Rep. No. Date
EvSltune
H
LOCAL COPY
328'148
Name of Person Sealing Well or Boring
I
HE -01,434-14 IC* 140-0423 ___
5/13R
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