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HomeMy WebLinkAbout2005-09-07 Well & Boring Sealed Record11/10/2005 10:18 FAX 6512223831 S empl e E xcavat ing INC 10 002 .. _ • '�- 4 SONS 4 6512223831 NO. 141 IP02 WM.L O BOW#= LOCAMW MINNESOTA DE PARTMENT OF HEA Mi Woli and B org � CO-M i So©1lnp No, 23948 WELL ANO BORING SEALING RECORD mirinarlota unique Wal Na. wnnawea Smanw, awpor ray; or w u r9ep No. wMa T� Netrw Tc�d'm� sip o, %rV No, e0C(O R No. Frnels*n (rm.a. fg) Dais Sdal6d DAIc Wall or Aarlog Gor�ntmd C*k Pa& -; 4 "N I 2 5 NE S August 26, 2005 Unkno" CPS LCAYI[M Nctrrro&:Zd 8noAddmn or Pra "ter and Glty of Woll or Bong Lcmw 5 769 Oalqpm Avs nue Wo Show axao �Omc*n of "9 of wftxta Skc[dch m¢tp d well or b�0�Y1 it km= on, ohawinp properly [Inca, rests, a nd huPdinoa, I f I 1 i oyr■ sq�■ w yp .ry. w ffffff + 1 E 1 , 1 1 4 • M + PwFw OWNER'S N11� MOMPANY` N,A,ME -sue- -- - - -- -- -- vkwmit U C mopoN ow*rx M4&w + 'g A t';ifl Tw W60 kocca on �gw &w uww x� abo" 760 SblwaW R oad xclhIOM MN 55115 lMKU CV&NEA13 NAMEACOMP NAME W90 owmes rr►4ry wsc�mm 0 df[d than pfoaee� an�ner` rows f��4 a�aovv 91 Ri dder St N4 MN 55107 Phoned (651) MY 449 f A U' Erw(s) gfim `-WATER LEVEL stnP >Aguitror [3 Mutlaqukor W111LUBOMNG ewluw e upptr Well Q MsX►k Neil Es i lmated Q Em. &a Mal ID Grhar 133 ft ebek w ] serve fend Surfed CASfNd YY11 je8twi p P ❑ miv p oaf WtsLLHFAD C owtuwa: ❑ wQ I l HOU60 IIJ%s3Aa: 0 196,50men t 0"MI XPAUSS ACL4ytst/U vl waf! Ph ❑1 C) �urfod 1 Q SLAW CASING(S) — pi4ma Of' Depth two to ovemiza flde7 Arkftlaf r.Noo rnitlwry gr4[ta47 4 In. frorn.,--.. Q.. to 1$4 0. ❑ Yed A ❑ You ji�1ao ❑ Um=wh in. barn .. in It. ❑ Yes 0 No ❑ d06 0 M ❑ U*ric wn in. from �. - ....�. -� �1 0 Yw ❑ No 0 Yew ❑ No ❑ urdtowr semen from 18a to 18 #t. open Hole Earn to h. AWSMMp Pfpe C1 Cheek W"[8) ❑ Dbbrls 0 Plfl ❑ No Dbtsbucticni Yypo of Obdtrum)cne (Dow ba) P 0k0tDG=&i. NATMAL COLOi I M Umt5649A m4M To Obsi rcifone removed? Mf Yes ❑ Na Descrlbc r# nw wxmn, VKICM wli waKf umftim ma Iml fmmy rwo or Imp PLif�IP fix- J IMwn_ a 17 Type QraW 170 s eRernot W 0 N Pruenl ❑ Omer .._... 2 MMDIa !]Ded YO SEAL ANNULAR SPACE JJMWE l 2 Da.S1NG OR CAS114G AND SORE HOSE: No Annular Swe Uslls ❑' Arinalar opaw gmutod whh [►amfe pipe ❑ Gar -;ng nweoM anMMft in. troy zc it, ❑ Parlom, wo 0 Removed I from I to ft, ❑ pellorafwl ❑ 1) &nowoo Type of perforator .� 0 Other 13AOUTINO kA MAL(S) [0 rte ba of wmant a 04 ibe,, one bag of bwftn)v a 64 Qtudng Neat went ,� , 0 tD 185 fL . yanfs 0a;5 AE]IJIR", SWURCE OF DATA, 01MCUMES IN SEALING GcolD F rom; 538 Oakgrmn A,vc N Wx! I-AmM M Ab MR 95 ftr ,Date Fate Lavd Tom: 9 7 SEALED Accordin to M N State Regulations MINK DEPT GF F#"TM CC]" H 2 3 94 8 7 l'mm tc R. yards bap from to tL I y ara bogs MEN WQ"G AND WAIN" ©rher unsealed aAd c+nwvd W011 or booting on prl Wy? 0 Vot I' YNC l 1&* marry? UCEN&ED OR REGISTE14CO OONTftAMA CaRYlFICAT10N M wM of Dorlftg *or, gadad In ocwOonvo vrllh Minnaarrra kgad, Chador 4725. "t'Z+o WW'rr Rion conWnae in 1hic repel is tfw to Iva boo a my kItiawledoo. EIL R=ff & Sol,% Iii 71015 COA119 - usiness lIIaffm ► Wane or Pe4 �+rrvn Afo, 09!07/0-5 �4LoAnelzad ,0qp sanforiva Sl�r�alflirn Cale Icavin N and a f PD rson i9sarn.9 Wert or Soong 12M m E INVOICE N0.:000433030000 CUSTONER NO. :06875 DATE: 08/31/05 SOLD T0: SEMPLE EXCAVATION 91 RIDDER CIRCLE ST - PAUL, MN,55107 SHIP TO: ABANDONMENT (H 239487) 5769 OAKGREEN AVENUE N OAK PARK HEIGHT, MN 55082 SALES- ORDER SHIP DATE SHIPPED VIA F.O.B. TERMS PERSON DATE P. 0. NUMBER 08/26/05 TONY/KEVIN NET 30 07 08/24/05 VERBAL-BRAD. SUB-TOTAL 1,440.00 SHIPPING CHARGES 0.00 T H A N K Y 0 U * SALES TAX 0.00 WHITE - CUSTOMER YELLOW - OFFICE PINK - REMITTANCE TOTAL if440.00 WELL SEAIING UNIT Q UANTITY DESCRIPTION PRICE AMOUNT 85.00 REMOVAL OF PUMPING EQUIPMENT 2.50 GROUTMASTER 1 SMEAL TRIP CHARGE /TRIP 85.00 85.00 1 SNEAL PUMP TRUCK /HR. 85.00 85.00 2.50 SERVICE TECHNICIAN /HR. 85.00 85.00 SUB-TOTAL 1,440.00 SHIPPING CHARGES 0.00 T H A N K Y 0 U * SALES TAX 0.00 WHITE - CUSTOMER YELLOW - OFFICE PINK - REMITTANCE TOTAL if440.00 WELL SEAIING 2 GROUTMASTER TRIP CHARGE /TRIP 85.00 170.00 2.50 GROUTMASTER /HR. 40.00 100.00 2.50 GROUTER-OPERATOR /HR. 85.00 212.50 2.50 GROUTER-HELPER /HR. 85-00 212.50 so c NT TYPE 1 PORTLAND 47LB /BAG 8.00 400.00 1 WELL ABANDONMENT REPORT /EA. 45.00 45.00 I PERMIT SEAIING FEE - MN /EA. 45-00 45.00 SUB-TOTAL 1,440.00 SHIPPING CHARGES 0.00 T H A N K Y 0 U * SALES TAX 0.00 WHITE - CUSTOMER YELLOW - OFFICE PINK - REMITTANCE TOTAL if440.00 11/10/2005 10:18 FAX Semple Excava ing INC - , 11'inm & SUNS 4 6512223831 E.H. Renner & From : L ori 0001 NO - x.41 CO1 So s incorporated LL DMLCN'G FOR FIVE GENERATIONS 156$8 Jarvis Sweet N.W. /Elk River, MN 55330 'hone: (763)427-6100/Fax-. (763)427-0533 Messap: Please note the address on the well log is "5769 ". VRenl spoke to you the address you gage me was "5679 ". Please call me if 1 ��.�d te:zhange tb, is record. Thank you,